DISEASES  OF  OCCUPATION 

AND 

VOCATIONAL  HYGIENE- 

EDITED  BY 

GEORGE  M.  KOBER,  M.D.,  LL.D. 

WASHINGTON,  D.  C. 
AND 

WILLIAM  C.  HANSON,  M.D. 

BELMONT,  MASS. 


CONTRIBUTORS 


JOHN  B.  ANDREWS,  Ph.  D., 

New  York  City,  N.  Y. 
IRENE  OSGOOD  ANDREWS, 

New  York  City,  N.  Y. 
GEORGE  L.  APFELBACH,  M.  D., 

Chicago,  III. 
BAILEY  K.  ASHFORD,  M.  D., 

San  Juan,  Porto  Rico. 
CLARENCE  JOHN  BLAKE,  M.  D., 

Boston,  Mass. 
JOHN  T.  BOWEN,  M.  D.. 

Boston,  Mass. 
LOUIS  CASAMAJOR,  M.  D., 

New  York  City,  N.  Y. 
C.  H.  CROWNHART,  LL.  B., 

Madison,  Wisconsin. 
PROF.  DR.  L.  DEVOTO, 

Milan,  Italy. 
SEWARD  ERDMAN.  M.  D., 

New  York  City,  N.  Y. 
LANGDON  FROTHINGHAM,  M.  D.  V., 
Boston,  Mass. 
ALICE  HAMILTON,  M.  D., 

Chicago,  III. 
EMERY  R.  HAYHURST,  M.  D., 

Columbus,  Ohio. 
CHARLES  R.  HENDERSON,  Ph.  D.. 

Chicago,  III. 
HARRY  V.  WURDEMANN, 


FREDERICK  L.  HOFFMAN.  Ph.  D.. 

Newark,  N.  J. 
FREDERIC  S.  LEE.   Ph.  D,. 

New  York  City,  N.  Y. 
THOMAS  S.  LEE,  M.  D., 

Washington,  D.  C. 
THOMAS  M.  LEGGE.  M.  D.. 

Whitehall,  Londo.v,  England. 
HARRY  LINENTHAL,  M.  D., 

Boston,  Mass. 
OWEN  R.  LOVE  JOY, 

New  York  City,  N.  Y. 
SIR  THOMAS  OLIVER,  M.  D., 

Newcastle-upo.n-Tyne,  England. 
THOMAS  ORDWAY,  M.  D., 

Albany,  New  York. 
HARRY  C.  SOLOMAN,  M.  D., 

Boston,  Mass. 
ELMER  E.  SOUTHARD,  M.  D., 

Boston,  Mass. 
PROF.  DR.  LUDWIG  TELEKY, 

Vienn.\. 
JOHN  W.  TRASK,  M.  D., 

W.^shington,  D.  C. 
ERNEST  E.  TYZZER,  M.  D., 

Boston,  M.a.ss. 
GEORGE  C.  WHIPPLE,  S.  B., 

Cambridge,  Mass. 
vl.  D  ,  oe^ttie,  Washington. 


WITH  ILLUSTRATIONS  AND  ktFERENCE  TABLES 


PHILADELPHIA 

P.    BLAKISTON'S   SON   &   CO. 

1012  WALNUT  STREET 


Copyright,  1916,  by  P.  Blaktston's  Son  &  Co. 


V    <  I   H    It       V  X 


^0 


GEORGE  MILLER   STERNBERG,  M.  D.,  LL.  D. 

A   PIONEER   IN    PREVENTIVE    MEDICINE    IN   THE    UNITED 
STATES    TO    WHOM    THE    SENIOR    EDITOR    IS    IN- 
DEBTED   FOR    AID    AND    ENCOURAGE- 
MENT    IN     HIS     WORK 


AND 


HENRY  PICKERING  WALCOTT,  M.  D.,  LL.  D. 

PRESIDENT,    FIFTEENTH    INTERNATIONAL   CONGRESS    OF 

HYGIENE    AND    DEMOGRAPHY    TO    WHOM    THE 

JUNIOR   EDITOR   IS   INDEBTED  FOR    THE 

OPPORTUNITIES     OF     ACQUIRING 

A  PRACTICAL  KNOWLEDGE 

OF  THE  SUBJECT 


3G9G01 


CONTRIBUTORS 


ANDREWS,  JOHN  B.,  Ph.  D. 

Secretary  of  the  American  Association  for  Labor  Legislation;  Editor  of  the  American 
Labor  Legislation  Review. 

ANDREWS,  IRENE  OSGOOD. 

Assistant  Secretary  of  the  American  Association  for  Labor  Legislation. 

APFELBACH,  GEORGE  L.,  M.  D. 

Physician  to  the  Medical  Division  of  the  Illinois  State  Department  of  Factory 
Inspection. 

ASHFORD,  BAILEY  K.,  M.  D.,  Sci.  D.  (Georgetown). 

Major,  Medical  Corps,  U.  S.  Army;  President  of  a  Board  for  the  Study  of  Tropical 
Diseases  as  they  Exist  in  Porto  Rico,  Cooperating  with  the  Institute  of  Tropical 
Medicine  and  Hygiene  of  Porto  Rico. 

BLAKE,  CLARENCE  JOHN,  M.  D.,  O.  M.  (Vienna). 

Professor  of  Otology,  Emeritus  (Harvard) ;  Fellow  American  Academy  of  Arts  and 
Sciences;  Fellow  American  College  of  Surgeons;  President  Ninth  International 
Otological  Congress. 

BOWEN,  JOHN  T.,  M.  D. 

Professor  of  Dermatology,  Emeritus  (Harvard). 

CASAMAJOR,  LOUIS,  M.  D. 

Assistant  Professor  of  Neurolog}',  College  of  Physicians  and  Surgeons,  Columbia 
University,  New  York  City;  Chief  of  Clinic,  Neurological  Department  Vanderbilt 
Clinic;  Assistant  Neurologist,  City  Hospital. 

CROWNHART,  C.  H.,  LL.  B. 

Chairman  of  the  Industrial  Commission  of  Wisconsin. 

DEVOTO,  DR.  LUIGI. 

Professor  and  Director  of-  the  Milan  Clinic  for  Occupational  Diseases;  Professor 
of  Internal  ]\Iedicine,  Emeritus,  at  the  Royal  University  of  Pavia,  Italy. 

ERDMAN,  SEWARD,  M.  D. 

Instructor  in  Clinical  Surgery  at  the  Cornell  University  Medical  College,  New  York 
City;  Adj.  Asst.  Surgeon  to  the  BeUevue  Hospital;  Member  of  Medical  Staff  East 
River  Tunnels  Contract  During  2}^  Years'  Construction. 

FROTHINGHAM,  LANGDON,  M.  D.  V. 

Pathologist  to  the  State  Department  of  Animal  Industry  of  Massachusetts. 

HAMILTON,  .ALICE,  M.  D. 

Special  Investigator  of  Industrial  Lead  Poisoning  for  the  U.  S.  Bureau  of  Labor 
Statistics,  Washington,  D.  C;  Chairman  of  the  Section  on  Industrial  Hygiene, 
American  Public  Health  Association. 

HAYHURST,  EMERY  R.,  M.  D. 

Chief  of  the  Occupational  Disease  Survey,  State  of  Ohio,  1913;  Director  of  the 
Division  of  Occupational  Diseases,  State  Board  of  Health  of  Ohio;  Vice  Chairman 
of  the  Section  on  Industrial  Hygiene  of  the  American  Public  Health  Association. 

HENDERSON,*  CHARLES  R.,  Ph.  D. 

Professor  of  Sociology,  University  of  Chicago;  Secretary  of  the  Illinois  Commission 
on  Industrial  Insurance,  1907;  Secretary  of  the  Illinois  Commission  on  Occupa- 
tional Diseases,  igii. 

HOFFMAN,  FREDERICK  L.,  LL.  D.,  F.  S.  S.,  F.  A.  S.  A. 

Statistician  of  the  Prudential  Life  Insurance  Company,  Newark,  N.  J. 

*Deceased, 


VI  CONTRIBUTORS 

LEE,  FREDERIC  S.,  Ph.  D. 

Dalton  Professor  of  Physiology  in  Columbia  University,  New  York  City. 

LEE,  THOMAS  S.,  M.  D. 

Clinical  Professor  of  Medicine,  Georgetown  University,  Washington,  D.  C;  .\ttend- 
ing  Physician  to  the  Asylum  Hospital;  Consulting  Physician  to  the  Providence 
Hospital. 

LEGGE,  THOMAS  M.,  M.D.,  D.  P.  H     (Comb.,  Eng.,  1893). 

H.  M.  Med.  Insp.  of  Factories;  Sect.  Fact.  Hyg.  Univ.  Manch.;  Sec.  Roy.  Commiss. 
on  Tuberculosis,  1896-1898. 

LINENTHAL,  HARRY,  M.  D. 

Physician  to  Out-patients,  Massachusetts  General  Hospital,  Boston. 

LOVEJOY,  OWEN  R. 

General  Secretary  of  the  National  Child  Labor  Committee,  New  York  City. 

OLIVER,  SIR  THOMAS,  M.  D.,  F.  R.  C.  P.,  M.  A.  (Hon.). 

From  Durham,  LL.  D.,  Glasgow,  D.  Sc,  Sheflield;  Consulting  Physician  to  the  Royal 
Victoria  Infirmary,  Newcastle-upon-Tyne;  Professor  of  the  Principles  and  Prac- 
tice of  Medicine  of  Durham  University. 

ORDWAY,  THOMAS,  M.  D. 

Dean  and  Associate  Professor  of  IMedicine,  Albany  Medical  College,  Albany,  New 
York;  Attending  Physician  to  the  Albany  Hospital;  Formerly  Physician-in-Charge 
of  the  CoUis  P.  Huntington  ^Memorial  Hospital,  Boston,  Mass. 

SOLOMAN,  HARRY  C,  M.  D. 

Assistant  in  Neuropathology,  Medical  School  of  Harvard.  University;  Junior  As- 
sistant Physician,  Psychopathic  Department  of  the  Boston  State  Hospital. 

SOUTHARD,  ELMER  E.,  M.  D. 

BuUard  Professor  of  Neuropathology,  ^Medical  School  of  Harvard  University; 
Pathologist  to  the  Massachusetts  State  Board  of  Insanity;  Director  of  the  Psy- 
chopathic Department  of  the  Boston  State  Hospital. 

TELEKY,  DR.  LUDWIG. 

Privat  Dozent  for  Social  Medicine  at  the  University  of  Vienna. 

TRASK,  JOHN  W.,  M.  D. 

-Assistant  Surgeon  General,  U.  S.  Public  Health  Service. 

TYZZER,  ERNEST  E.,  M.  D. 

s-f   1^     .\ssistant  Professor  of  Pathology,  Medical  School  of  Harvard  University;  Director 
of  the  Collis  P.  Huntington  Memorial  Hospital,  Boston. 

WHIPPLE,  GEORGE  C,  S.  B. 

Professor  of  Sanitary  Engineering,  Massachusetts  Institute  of  Technology;  Gordon 
McKay  Professor  of  Sanitary  Engineering,  Harvard  University;  Secretary  of  the 
Administrative  Board  of  the  School  for  Health  Officers  conducted  by  Harvard 
University  and  the  Massachusetts  Institute  of  Tcchnoh>gy. 

WiJRDEMANN,  H.  V.,  M.  D. 

Publisher  and  Managing  Editor;  Managing  Editor  of  Ophthalmology;  .\ssociati' 
Editor  of  Ophthalmic  Record. 

EDITORS 

KOBER,  GEORGE,  M.,  M.  D.,  LL.  D. 

Professor   of   Hygiene,  Georgetown  University,  Washington,   D.   C. ;  President  of 
the  Section  on  Hygiene  of  Occupations,  XV  International  Congress  on  Hygiene  and 
Dem()gra[)hy;  Chairman  of  the  Section  on  Industrial  Hygiene  of  tlie  .\merican  Publi 
Health  .Association  (1915);  Secretary  of  the  Association  of  Amtrir.-in  Phv^iiian'^ 

HANSON,  WILLIAM  C,  M.  D. 

Formerly  with  the  Massachusetts  State  Board  of  Health. 


PREFATORY 


Historical  Review 

One  of  the  most  interesting  and  beneficient  subdivisions  of  hygiene  is  a 
study  of  the  relations  of  occupations  to  the  health  and  longevity.  The 
necessity  of  devoting  special  attention  to  this  subject  was  shown  long  ago  by 
observations  made  by  Hippokrates  and  Galen  that  certain  occupations  and 
trades,  even  in  those  primitive  periods,  were  dangerous  to  health.  These 
and  subsequent  authors  refer  to  their  writings  to  occupational  diseases  of 
miners,  bearer  of  burdens,  messengers,  sailors,  soldiers,  chemists  and  profes- 
sional men,  but  the  first  systematic  treatise  on  Diseases  of  Occupation  was 
written  by  Professor  Bernado  Ramazzini  of  the  University  of  Padua,  in  Italy. 
His  Monograph  "De  Morbis  Artificium  Diatriba"  published  in  1700  was 
translated  into  English  in  1705  and  also  into  French  in  1711.  It  awakened  a 
deep  interest  in  these  countries  and  also  in  Germany. 

Space  will  not  permit  to  trace  the  rise  and  growth  of  domestic  and  handi- 
craft industrial  production  and  its  influence  upon  the  health  of  the  operatives, 
which  doubtless  was  very  important  when  we  recall  the  primitive  workshops 
of  the  mediaeval  towns  and  cities.  There  is  evidence  to  show  that  the  factory 
system  originated  in  the  beginning  of  the  sixteenth  century,  since  we  read 
of  woolen  cloth,  linen  factories,  dye  establishments,  hat  and  soap  factories, 
sugar  refineries,  etc.,  both  in  England  and  Germany,  where  large  numbers  of 
carders,  spinners,  weavers  and  other  operatives  were  employed.  The  modern 
factory  system  probably  started  in  the  latter  part  of  the  eighteenth  century. 
Stieda  informs  us  that  Germany  prior  to  1801  had  about  20  factories,  employ- 
ing between  100  and  500  persons.  It  is  quite  natural  that  the  first  mechanical 
industries  should  have  been  devoted  to  the  production  of  material  for  clothing. 

The  Spinning  Jenny  invented  and  perfected  by  High,  Kay  &  Hargreaves 
in  1767  supplemented  by  Arkwright's  spinning  machine  in  1771,  and  Cart- 
wright's  power  loom  patented  in  1785  laid  the  foundation  for  the  textile 
industry  on  a  large  scale.  With  the  discovery  of  the  steam  engine  and  its 
application  to  factories  in  1785  a  tremendous  rise  in  the  mechanical  and  manu- 
facturing industries  occurred.  This  is  shown  by  the  fact  that  the  importa- 
tion of  raw  cotton  into  England  increased  from  5,000,000  lb.  in  1775  to 
273,249,653  in  1 83 1  and  also  by  an  unusual  demand  for  labor,  especially 
apprentices  and  child  labor  to  feed  the  machines. 

With  the  development  of  the  modern  factory  system  of  increased  produc- 
tion, came  also  a  concentration  of  the  population  in  certain  manufacturing 

vii 


Vlll  PREFATORY 

districts,  as  witnessed  by  an  increase  of  the  population  in  the  Lancashire  Dis- 
trict from  166,200  in  1700  to  1,336,854  in  1831.  But  most  important  of  all, 
occupational  diseases  and  accidents  assumed  more  and  more  importance.  It 
soon  became  apparent,  in  countries  like  England,  France,  Germany  and 
Italy,  that  Ifeath  was  exacting  a  very  heavy  toll  in  many  of  the  industries. 
Indeed  the  workmej^n  these  countries  began  to  believe  that  steam  and  speed 
had  not  improved  their  lot  in  life  and  "spoke  of  their  condition  as  one  of 
slavery,  and  of  their  fac^ries  and  workshops  as  "slaughter  houses." 

This  was  not  an  unreasonable  conclusion,  when  it  is  recalled  that  in  1833 
in  factory  towns  like  Manchester  and  elsewhere  "the  youthful  population 
was  physically  worn  out  before  manhood  "  and  the  average  age  of  the  laboring 
classes  was  only  22  years,  as  compared  with  44  years  among  the  higher  classes. 
£^k  later  there  was^  period  when,  with  a  general  death  rate  for  the  whole 
of  England  of  22  peffooo,  the  death  rate  in  the  laboring  districts  was  36  out 
of  every  1000  per  annum. 

In  the  interest  of  humanity,  and  as  a  matter  o^^cial  and  political 
economy,  it  became  imperative  to  study  the  so-calle^^B[gerous  trades  to 
determine  the  sources  and  significance  of  the  dangers  aW»nie  possible  means 
for  the  prevention  and  mitigation  of  the  injurious  effects.  In  the  meantime 
Sir  Robert  Peel  had  caused  the  enactment  of  laws  in  England,  as  early  as 
1802,  for  the  protection  of  the  health  and  morals  of  apprentices  and  others 
employed  in  cotton  and  other  mills  and  factories,  which  limited  the  hours  of 
work  to  i2*hours  a  day,  and  made  provisions  for  general  cleanliness  and  also 
for  periodical  inspections  by  a  Justice  of  the  Peace  and  a  Clergyman.  In 
1 81 6  and  in  1^3  the  English  Parliament  appointed  a  commission,  to  inquire 
into  the  cond^)n  of  factories,  which  resulted  in  1833  in  placing  an  age  limit 
on  child  labor,  in  the  appointment  of  four  regular  factory  inspectors  and  in 
the  enactment  of  special  rules  for  the  white-lead  industry  and  bake  houses, 
etc.  In  1844  the  employment  of  children  under  8  years  of  age  in  factories 
was  forbidden  and  female  labor  was  restricted.  In  1847  the  hours  of  labor 
for  wom^i^nd  children  were  limited  to  10  hours  a  day.  In  1854  a  law  requir- 
ing machinery  guards  was  enacted.  In  1864  certain  occupations  were 
declared  dangerous  and  in  1867  a  law  compelling  the  installation  of  appliances 
for  the  removal  of  dust  was  enacted.  An  Act  of  1878  permitted  children  to 
be  employed  at  the  age  of  10  years,  but  excluded  them  from  work  in  certain 
of  the  processes  in  the  white-lead  industry.  The  Act  of  1891  raised  the 
age  limit  to  11,  which  has  since  been  raised  to  13  and  14.  This  Act  also 
included  workshops,  under  the  provisions  of  all  factory  acts  and  placed  the 
supervision  of  the  sanitary  condition  of  the  workshops  in  the  hands  of  the 
local  sanitary  authorities.  In  looi  increased  j')owors  and  duties  wore  con- 
ferred upon  medical  officers  of  health.  In  1897  the  Workmens'  Compensa- 
tion Act  was  passed,  which  was  amended  in  1900  and  again  in  1906.  Other 
countries  followed  the  lead  of  England.  In  iSio  the  French  Government 
issued  a  decree  relating  to  "establissenients  dangereaux  insalul)res  et  incom- 


PREFATORY  IX 

modes"  and  in  1839  the  Academic  des  Sciences  morales  et  politiques  de 
France"  and  subsequently  Prussia,  Bavaria  and  other  German  states  directed 
similar  investigations. 

In  the  prevention  of  the  fundamental  cause  of  poverty  and  distress  the 
medical  profession  has  been  a  help  mate  to  religion.  Men  who  come  into 
daily  contact  with  sickness  and  sorrow  cannot  fail  to  experience  a  deep 
sympathy  for  their  fellow  men,  which  is  all  the  more  profound  when  they 
realize  that  many  of  the  diseases  are  preventable  and  hence  much  of  human 
suffering  cruelly  unnecessary.  As  a  result,  a  special  department  of  Social 
Medicine  has  been  created  with  a  most  complete  and  satisfactory  literature 
of  its  own.  As  early  as  1822  C.  Turner  Thackrah,  of  Leeds,  wrote  a  mono- 
graph on  the  effects  of  the  Arts,  Trades,  and  Professions,  and  of  civic  States 
and  Habits  of  living,  on  Health  and  Longevity."  In  the  same  year  Patissier 
wrote  his  "Traite  des  Maladies  des  Artisans"  and  in  1845,  Halford,  of  Ger- 
many, published  a  very  important  work  on  occupational  diseases.  Since 
which  time  numerous  contributions  on  the  causes,  mortality  and  prevention 
of  occupational  diseases  and  the  hygiene  of  occupations  have  appeared. 
German  authors,  under  the  leadership  of  Theodor  Weyl,  in  1897  issued  a 
volume  of  over  1200  pages,  and  English  authors  under  the  Editorship  of  Dr. 
(now  Sir  Thomas)  Oliver  devote  891  pages  to  "Dangerous  Trades:  The 
Historical,  Social  and  Legal  aspects  of  Industrial  Occupations  as  affecting 
Health." 

These  monumental  volumes  are  especially  mentioned  because  the  con- 
tributors were  recognized  experts  on  the  various  subjects  and  hence  their 
conclusions  should  carry  great  weight.  This  in  no  way  sould  be  construed 
as  underrating  the  value  of  pioneer  workers  hke  Thackrah,  Halford,  Arlidge, 
Eulenberg,  Hirt,  Patissier,  Layet,  Oldendorflf,  Roth,  Albrecht,  Sommerfeld, 
Dammer  and  a  host  of  others,  whose  writings  will  always  remain  monuments 
of  careful  study,  accurate  observation,  great  industry  and  faithful  devotion 
te  a  noble  cause. 

"-  These  individual  studies,  and  numerous  governmental  investigations, 
have  supphed  more  accurate  information  concerning  the  causes  of  disease 
and  accident — hazards  in  different  occupations  and  have  provided  forceful 
argument  for  protective  legislation  and  education.'  Much  has  been  accom- 
plished, in  the  way  of  industrial  and  social  betterment,  by  the  establishment 
of  industrial  insurance,  the  erection  of  sanitary  homes  for  wage  earners,  and 
the  enactment  of  workmen's  compensation  laws  in  case  of  accident  or  injury, 
from  occupational  diseases,  contracted  in  the  line  of  duty.  In  the  way  of 
educational  methods,  industrial  museums  of  safety  have  been  established 
in  14  Eiuropean  cities.  The  Berhn  Museum  estabhshed  in  1904  and  the 
Vienna  Museum  founded  in  1909  are  typical  examples  of  what  may  be  done  in 
illustrating  the  cause  and  prevention  of  occupational  diseases  and  accidents. 
In  the  Berlin  Museum,  located  at  Charlottenburg,  every  safety  appliance 
which  inventive  genius  has  devised  can  be  seen  in  practical  operation.     The 


X  PREFATORY 

different  labor  unions  appear  to  profit  immensely  by  the  special  lectures  and 
demonstrations  which  are  given  on  Sundays  or,  upon  request,  at  any  con- 
venient time,  by  men  formerly  employed  in  "Dangerous  Trades."  Apart 
from  safety  devices  for  machinery  and  appliances  for  the  removal  of  dust  and 
injurious  gases,  all  improved  methods  calculated  to  diminish  danger,  as  for 
example,  in  the  manufacture  of  white  lead,  etc.,  are  illustrated  by  models  and 
descriptive  text,  printed  leaflets  being  distributed  free  of  charge.  Here  to, 
may  be  seen  the  latest  and  best  types  of  respirators,  wire  masks,  goggles, 
illuminating  appUances,  first-aid  kits,  safety  working  suits,  etc.  Only  meri- 
torious objects  are  displayed,  and  they  are  replaced  by  newer  and  more  satis- 
factory types.  One  of  the  most  interesting  collections  consists  of  a  series  of 
raw  materials,  a  series  of  bottles  containing  dust  evolved  from  such  material, 
a  series  of  photographs  showing  the  microscopical  character  of  this  dust,  and 
last,  but  not  least,  anatomical  specimens  and  microscopical  sUdes,  showing  the 
effect  of  dust  upon  the  respiratory  organs  of  the  human  subject.  Models, 
plans  and  photographs  of  sanitary  homes  for  wage  earners  with  exterior  and 
interior  decorations  have  a  prominent  place  in  the  exhibit.  The  display  of 
food  stuff,  and  data  relating  to  their  nutritive  and  economic  value  together 
with  instructive  pamphlets,  such  as  "How  to  keep  well  and  capacitated  for 
work,"  "Good  food  at  reasonable  cost,"  "The  Alcohol  Question,"  "The 
Social  Evil,"  etc.,  form  part  of  this  interesting  exhibition.  In  1906  the  first 
International  Congress  on  Occupational  Diseases  was  held  at  Milan,  which 
city  has  also  the  proud  distinction  of  establishing  the  first,  and  so  far  the 
only  hospital  and  cHnic  for  the  treatment,  study  and  prevention  of  Occupa- 
tional Diseases.  A  report  of  the  activities  of  this  cUnic  by  its  distinguished 
Director  Professor  L.  Devoto  will  be  found  on  page  765 .  These  measures  and 
the  establishments  of  laboratories  in  connection  with  the  universities  for  the 
development  of  industrial  hygiene,  and  the  formation  of  Research  Institutes 
for  Industrial  Hygiene,  such  as  the  one  at  Frankfort  on  the  Main,  in  1910, 
have  been  most  beneficient  in  the  interest  of  wage  earners. 

Progress  of  Industrial  Hygiene  in  the  United  States 

As  in  Europe  so  in  this  country  the  mechanical  industries  had  their  origin 
in  the  textile  industry.  According  to  Wright  cited  ])y  Price,  the  first  spin- 
ning jenny  in  this  country  was  exhibited  in  IMiiladeliihia  in  1775.  The  first 
cotton  factory  to  apply  Arkwright's  invention  was  started  with  three  cards 
and  72  spindles  in  Rhode  Island  in  1700,  by  Samuel  Slater  of  England.  It  is 
reported,  however,  by  a  writer  in  the  Annriian  Museum  {or  July,  1790,  that 
a  man  in  South  Carolina,  completed  and  had  in  operation  on  the  Santee, 
ginning,  carding  and  other  machines  (lri\i'n  by  water  and  also  spinning 
machines  with  84  spindli-s  i-adi.  Wahhani,  .Mass.,  iias  the  credit  of  having 
set  up  the  first  power  loom  in  1S14,  and  of  having  estabhshed  for  the  first 
lime  in  history,  a  factory  in  which  all  the  processes  involved  in  the  manu- 


PREFATORY  xi 

facture  of  goods  from  the  raw  material  to  the  finished  product  were  carried 
on  in  one  estabHshment. 

The  wonderful  progress  in  the  cotton  textile  industry  in  the  United  States 
is  shown  by  the  increase  of  spindles  from  4500  in  1805  to  1,246,703  in  1831. 
As  in  England  so  in  this  country  the  application  of  machinery  resulted  in  the 
exploitation  of  child  labor.  It  cannot  be  said,  that  we  followed  the  example 
of  England  to  the  extent  of  trafficking  with  the  poor  law  officials,  who  accord- 
ing to  Price  sold  the  children  of  paupers  in  a  form  not  different  from  the 
methods  of  ancient  and  modern  slave  dealers.  It  is  reported,  however,  by 
Price  that  the  first  cotton  mill  established  in  1790  in  Rhode  Island  began  to 
work  with  four  spinners  and  carders,  but  five  children  were  soon  added, 
whose  ages  ranged  from  7  to  12  years,  and  in  1831  the  number  of  children 
working  in  the  cotton  mills  of  that  state  was  almost  one-half  of  the  total 
number  of  employees. 

According  to  Miss  S.  S.  Whittelsey's  essay  on  Massachusetts  labor  legis- 
lation, the  subject  of  Child  Labor  received  attention  in  1836.  The  Act 
provided  for  at  least  3  months  schooling  during  the  working  year  for 
every  child  employed  under  the  age  of  15,  which  was  amended  in  1842  by 
fixing  a  lo-hour  working  day  for  children  under  14  years.  Similar  legislation 
was  enacted  in  Connecticut  in  1842,  in  Maine  in  1847,  and  after  20  years 
agitation  also  in  Pennsylvania  in  1848.  Massachusetts  was  also  the  first 
state  to  enact  a  law  in  1852  as  regards  safety  of  steam  machines  and  by  an 
Act  of  1870  also  required  super\dsion  of  steam  boilers,  but  it  was  not  until 
1877  that  this  state  enacted  a  law  setting  forth  certain  requirements  for  the 
removal  of  dust.  Since  this  time  nearly  all  of  the  states  have  enacted  some 
form  of  factory  legislation,  but  even  at  the  present  time  only  22  states  have 
provisions  for  protection  against  injurious  dust,  15  require  notification  of 
certain  occupational  diseases,  12  states  have  legislated  against  defective 
lighting  and  11  on  the  subject  of  temperature  and  humidity.  There  is  a 
distinct  need  for  a  definite  standardization  of  factories  with  reference  to 
construction,  fire  protection,  light,  air,  space,  ventilation,  safety  against 
accident  and  general  sanitation.  A  lack  of  appreciation  of  the  importance 
of  enforcing  existing  legislation  is  clearly  evinced  by  the  fact  that  even  the 
State  of  Massachusetts  made  no  provisions  until  1888  for  a  separate  depart- 
ment of  factory  inspection,  the  duties  having  been  performed  up  to  that  time, 
by  truant  officers  and  members  of  the  pohce  force. 

In  the  mean  time  the  Department  of  Labor  has  published  a  number  of 
interesting  studies,  notably  the  essays  on  "Employer  and  Employees"  by 
D.  H.  Olmsted  and  S.  D.  Fessenden,  in  Bulletin  i;  "The  Sweat  System"  by 
Henry  White,  Bulletin  4;  "  The  Inspection  of  Factories  and  Workshops  in  the 
United  States"  by  William  F.  Willoughby,  Bulletin  12;  "The  Production  of 
Paper  and  Pulp,"  Bulletin  23;  "Protection  of  Workmen  in  their  Employ- 
ment" by  S.  D.  Fessenden,  Bulletin  26  and  also  numerous  articles  on  foreign 


Xll  PREFATORY 

labor  laws.     These  writings  have  done  much  to  stimulate  the  enactment  of 
labor  and  factory  laws. 

In  1902  Dr.  Kober,  upon  request  of  the  Hon.  Carroll  D.  Wright,  Commis- 
sioner of  the  Bureau  of  Labor  recommended  his  former  student  Dr.  C.  F. 
W.  Doehring  for  the  purpose  of  making  an  investigation  into  the  manufacture 
of  white  lead,  paint,  etc.  The  manufacture  of  linseed-oil,  oilcloth  and  lino- 
leum, and  the  manufacture  of  tallow,  fertilizers,  etc.  The  results  of  this 
investigation  were  published  under  the  title  of ''  Factory  Sanitation  and  Labor 
Protection"  in  Bulletin  44,  January,  1903.  In  1905  the  State  Board  of 
Health  of  Massachusetts,  being  the  first  State  in  the  Union  to  recognize  the 
fact  that  sanitary  inspection  of  factories  was  essentially  a  public-health  mat- 
ter, submitted  a  brief  report  on  "The  Conditions  Affecting  the  Health  and 
Safety  of  Employees  in  Factories  and  Other  Establishments."  This  report 
was  supplemented  in  1907  by  a  more  exhaustive  report  and  also  by  an 
exhibition  of  90  photographs.  This  was  in  fact  the  first  exhibit  in  America 
relating  to  occupational  diseases.  The  photographs,  based  upon  a  study  of 
dusty  trades  in  Massachusetts,  by  Dr.  William  C.  Hanson,  together  with  the 
charts,  and  a  collection  of  dust  and  other  materials,  demonstrated  in  a  most 
effective  manner  that  many  of  the  insanitary  surroundings  and  injurious 
factors  in  the  leading  industries  are  due  to  neglect  of  perfect  ventilation,  and 
hence  are  to  a  great  extent  avoidable.  In  September,  1907,  during  the 
International  Congress  on  Hygiene  at  Berlin  the  Senior  Editor  met  Dr.  E.  J. 
Neisser,  who  had  just  completed  an  International  Review  of  Industrial 
Hygiene  covering  a  volume  of  352  printed  pages.  Dr.  Neisser  deplored  his 
inability  to  present  an  extended  review  of  the  work  accomplished  in  the 
United  States,  since  with  the  exception  of  one  or  two  states,  no  data  concern- 
ing factory  sanitation  were  available. 

Realizing,  as  Chairman  of  the  Committee  on  Social  Betterment  of  the 
President  Homes  Commission,  the  importance  of  the  subject,  not  only  to 
wage  earners,  but  to  all  interested  in  the  conditions  under  which  our  fellow 
men  and  women  live  and  work,  Dr.  Kober  in  February,  1908,  submitted  a 
report  on  Industrial  and  Personal  Hygiene  covering  175  pages.  This  was 
followed  in  December,  1908,  by  a  Report  of  the  Committee  on  Social  Better- 
ment covering  281  pages.  It  was  hoped  that  this  somewhat  hasty  study  of 
the  causes  of  sickness,  and  the  means  of  promoting  industrial  ethciency  and 
earning  power,  would  direct  attention  to  the  need  of  a  more  critical  study,  and 
of  remedial  legislation  in  this  Country.  This  hope,  thanks  to  the  medical 
and  lay  press  and  the  interest  aroused  among  ollicials  and  social  workers,  has 
been  realized.  In  November,  1908  and  May,  1909,  Dr.  Frederick  L.  Hoff- 
man's valuable  monographs  on  "The  Mortality  from  Consumption  in  Dusty 
Trades,"  were  published  by  the  U.  S.  Ihireau  of  Labor.  In  January,  1910, 
the  Epoch-making  report  by  Dr.  John  B.  Andrews  on  "Phosphorous  Poison- 
ing, in  the  Match  Industry  in  the  United  Stales,"  appeared  in  Bulletin  86  of 
the  same  Bureau.     In  1910  the  "Illinois  Stale  Commission  on  Occupational 


PREFATORY  XHl 

Diseases"  began  its  labors  and  in  191 1  published  a  large  number  of  specific 
instances  of  industrial  poisoning  contracted  by  wage  earners  in  the  course  of 
their  employment.  In  June,  19 10,  the  "  First  National  Conference  on  Occupa- 
tional Diseases"  was  held  at  Chicago,  and  in  the  memorial  to  President  Taft 
it  was  estimated  that  13,000,000  cases  of  sickness,  involving  an  economic 
loss  of  nearly  three-fourths  of  a  billion  dollars,  occurred  annually  among  the 
artisans  and  craftsmen  of  the  United  States.  In  July,  191 1,  the  Bureau  of 
Labor  pubhshed  in  Bulletin  95  the  result  of  an  intensive  study  by  Dr.  Alice 
Hamilton,  which  disclosed  388  cases  of  lead  poisoning,  of  which  16  were  fatal 
in  the  white  lead  and  lead  oxide  industries  in  the  United  States  from  January 
I,  1910  to  April  30,  1911.  The  same  bulletin  also  contained  a  report  by  Dr. 
John  B.  Andrews  on  60  deaths  from  industrial  lead  poisoning  actually  report- 
ed in  New  York  in  1909  and  1910.  The  report  of  lead  poisoning  in  potteries, 
tile  works  and  porcelain-enameled  sanitary  ware  factories  by  Dr.  Alice 
Hamilton  and  her  admirable  monograph  on  the  hygiene  of  painters  were 
published  by  the  Bureau  of  Labor  statistics,  respectively  August  7,  191 2  and 
May  13,  1913.  These  were  followed  by  a  report  on  lead  poisoning  in  the 
smelting  and  refining  of  lead,  February  17,  19 14.  Dr.  William  C.  Hanson's 
monograph  on  the  dangers  to  workers  from  dust  and  fumes  and  methods  of 
protection  illustrated  with  62  photographs,  was  published  by  the  same 
Bureau,  August  12,  1913.  Apart  from  Illinois,  the  States  of  New  York, 
Wisconsin  and  Missouri  have  created  special  commissions  for  the  study  and 
prevention  of  occupational  diseases,  and  important  investigations  have  been 
made  by  Drs.  J.  H.  Lloyd;  George  M.  Price;  Mrs.  Lindon  W.  Bates;  Dr.  C.  T. 
Graham  Rogers;  Dr.  D.  L.  Edsall;  E.  E.  Pratt;  E.  R.  Hayhurst  and  numerous 
other  ofl&cial  and  private  investigators.  The  6th  International  Congress  for 
the  Prevention  of  Tuberculosis  held  in  Washington  in  the  faU  of  1908,  and 
the  15th  International  Congress  on  Hygiene  held  in  the  same  city  in  Sep- 
tember, 191 2,  with  their  excellent  exhibits  illustrating  the  dangers  of  numer- 
ous occupations,  stimulated  a  profound  interest  in  the  subject  of  industrial 
hygiene,  and  the  National  Association  of  Labor  Legislation  organized  in 
1908  and  numerous  independent  organizations  have  accomplished  excellent 
work  in  the  way  of  investigation  and  legislation.  In  191 1  the  American 
Museum  of  Safety  was  incorporated  under  a  special  charter  from  the  legis- 
lature of  New  York.  It  is  located  in  the  City  of  New  York  and  is  devoted 
"  to  the  safety,  health  and  welfare  of  industrial  workers  and  the  technique  and 
science  of  industry."  Dr.  Wm.  H.  Tolman  is  the  Director  of  the  Museum 
and  Dr.  N.  E.  Ditman  is  in  charge  of  the  department  of  industrial  hygiene. 
For  the  purpose  of  stimulating  invention  and  the  installation  of  safety  devices 
and  the  promotion  of  sanitation  in  all  industries  the  Museum  has  awarded 
a  number  of  medals. 

In  191 1  the  "National  Safety  Council"  was  organized  and  later  created 
a  section  on  Industrial  Hygiene  which  held  its  first  session  in  connection  with 
the  Fourth  Annual  Congress  of  the  National  Safety  Council  at  Philadelphia 


XIV  PREFATORY 

in  October,  191 5.  The  American  Public  Health  Association  also  created  a 
section  on  Industrial  Hygiene,  which  held  its  first  meeting  at  Rochester,  N.Y., 
in  September,  1915. 

In  191 2  the  U.  S.  Public  Health  Service  created  a  Division  on  Industrial 
Hygiene  with  Dr.  J.  VV.  Schereschewsky  in  charge  and  in  191 5  established  a 
research  laboratory  in  the  city  of  Pittsburgh,  Pa.  In  the  mean  time  excellent 
field  work  has  been  carried  on  in  some  of  the  mining  districts  and  in  various 
industries.  There  is  every  reason  to  believe  that  the  investigations  of  this 
division  will  accomplish  much  towards  a  standardization  of  industrial  plants, 
as  regards  sanitation,  equipment  and  the  prevention  of  accidents  and  also  in 
the  matter  of  medical  supervision  and  medical  relief  of  the  personnel. 

In  191 5  and  1916  the  U.  S.  Government  assembled  an  excellent  exhibit 
of  safety  devices  in  the  National  Museum  in  Washington.  This  exhibit, 
beginning  May  i,  1916,  will  become  a  railway  travelling  exhibit  and  visit 
every  important  industrial  city  in  the  United  States. 

While  the  out-patient  department  of  the  Massachusetts  General  Hospital 
in  Boston  and  the  Clinics  connected  with  some  of  the  University  hospitals 
in  New  York  City  and  elsewhere,  have  given  more  attention  to  the  study 
of  occupational  diseases  during  the  past  decade,  it  was  not  until  191 5,  that 
the  first  Clinic  exclusively  devoted  to  occupational  diseases  was  established 
in  this  country  by  authority  of  Dr.  S.  S.  Goldwater,  in  connection  with  the 
Health  Department  of  the  City  of  New  York.  It  is  hoped  that  this  example 
may  be  followed  by  other  American  cities. 

In  191 2  Miss  Josephine  Goldmark  of  New  York  published  a  very  com- 
prehensive Study  of  Fatigue  in  its  industrial  aspects. 

Dr.  W.  Gilman  Thompson  was  one  of  the  first  among  American  Phy- 
sicians to  appreciate  the  importance  of  occupational  diseases  from  the 
medical,  social  and  economic  point  of  view.  Apart  from  organizing  in  New 
York  City,  in  November,  191 1,  an  informal  committee  "for  the  purpose  of 
studying  occupational  diseases,  and  especially  for  cooperating  with  the 
State  Labor  Bureau,  in  furtherance  of  its  investigations,"  he  has  made  a 
number  of  valuable  contributions  to  the  literature,  the  latest  being  his  work 
on  "Occupational  Diseases,"  which  appeared  in  June,  1914.  Dr.  Geo.  M. 
Price's  latest  contribution  appeared  in  1914,  in  the  form  of  a  book  of  574 
pages,  entitled  "The  Modern  Factory." 

In  justice  to  the  publishers  of  the  present  volume,  it  should  be  stated 
that  the  Senior  Editor  declined  their  request  to  prepare  or  edit  a  book  on  the 
"Diseases  of  Occupation  and  Vocational  Hygiene"  in  the  early  part  of 
191 1,  because  the  scarcity  of  statistical  data  in  reference  to  disease  and 
accident-hazards  in  the  various  occupations  of  this  country,  had  compelled 
him  in  his  former  writings  to  get  most  of  his  facts  from  Eurojie  and  the 
State  of  Massachusetts. 

He  entertained  the  hope,  that  with  a  general  awakening  in  this  country, 
and  the  publication   of  the   transactions  of  Section  IV  of  the  XV   Inter- 


PREFATORY  XV 

national  Congress  of  Hygiene  and  Demography,  devoted  to  the  hygiene  of 
occupations,  over  which  he  was  called  to  preside,  additional  material  on  the 
diseases  of  occupation,  as  they  occur  in  various  states  of  the  Union,  and  in 
foreign  lands,  would  be  available.  This  hope  has  not  been  vain.  Then  in 
addition  to  the  transactions  of  Section  IV,  the  publication  of  the  latest  mor- 
tality statistics  by  the  U.  S.  Census  Bureau,  the  collection  of  industrial 
insurance  statistics  by  the  Metropolitan  Insurance  Company,  and  the 
issuance  of  monographs  covering  special  investigations  made  in  the  States, 
notably  by  Dr.  E.  R.  Hayhurst  in  Ohio,  in  191 5,  has  enabled  us  to  write  more 
authoritatively  than  ever  before  on  disease  and  accident-hazards  of  the 
American  worker.  Special  acknowledgment  is  made  to  Drs.  Henry  H.  Hazen 
and  JohnD.  Hird,  and  to  Professor  Charles  E.  ]SIunroe,  and  Mr.  Charles 
H.  Verrill  and  Mr.  R.  C.  Lappin  for  valuable  assistance. 

The  Editors. 


FOREWORD 


The  constant  aim  of  the  Editors  has  been  the  presentation  of  the  basic 
data  concerning  the  diseases  of  occupation  in  such  a  way  as  to  render  them 
available  not  only  to  physicians,  but  also  to  employers,  employees,  efl5ciency 
experts,  public  health  officials  and  legislators;  for  it  is  only  as  a  knowledge  of 
the  character,  gravity,  causes  and  prevention  of  these  diseases  is  diffused 
that  corrective  and  preventive  action  can  be  expected.  The  subject  matter 
here  presented  is  grouped,  therefore,  in  three  parts. 

Part  I  deals  with  the  Specific  and  Systemic  Diseases  of  Occupation.  It 
also  treats  of  Fatigue  and  the  Neuroses.  It  is  written  by  specialists  of  inter- 
national reputation  and  adapted  to  the  needs  of  medical  and  legal  experts, 
medical  examiners,  insurance  examiners,  practising  physicians,  teachers, 
students  and  others  desiring  accurate  scientific  information  relating  to  the 
pathology,  symptomatology  and  treatment  of  diseases  of  occupation. 

Part  II  deals  with  the  Causation  and  Prevention  of  Occupational  Diseases 
and  Accidents.  While  it  is  also  of  interest  to  physicians,  lawyers  and  effi- 
ciency experts,  its  chief  interest  should  be  with  employers,  employees,  public 
health  officials,  nurses  and  social  workers,  legislators,  and  others  actively 
interested  in  the  prevention  of  avoidable  occupational  hazards.  This  part 
of  the  book  also  contains  a  Hst  of  industrial  poisons  and  of  industries  and- 
processes  in  which  poisoning  may  occur,  and  also  tables  of  occupational 
mortality  and  morbidity  statistics,  arranged  in  alphabetical  order  for  con- 
venient reference. 

Part  III  is  intended  to  be  of  service  to  those  who  may  be  called  upon  to 
investigate  in  the  shop,  the  factory,  in  the  dispensary  and  hospital  the  rela- 
tions of  occupation  to  disability  and  disease.  This  portion  has  been  framed, 
too,  in  the  hope  that  it  may  stimulate  the  teachers  of  the  coming  generation 
of  physicians  to  impart  to  their  pupils  a  better  knowledge  of  occupational 
diseases  and  their  prevention,  which  after  all  is  of  more  economic  importance 
than  their  cure. 

The  Editors  have  endeavored  to  make  the  book  a  safe  and  convenient 
guide  to  all  who  may  be  interested  in  the  study  of  occupational  diseases. 
They  ask,  therefore,  the  kind  indulgence  of  the  reader  who  may  discover  in 
it  errors  or  shortcomings  and  will  be  glad  to  have  such  defects  brought  to 
their  attention. 


xvu 


CONTENTS 


PART  I 


Specific  and  Systemic  Diseases  of  Occupation,  Fatigue 
and  Neuroses,  Etc. 


DIVISION  I.     SPECIFIC  OCCUPATIOX.AL  DISEASES 

Page 

CHAPTER         I.     Occupational  Intoxications 3-157 

Section         I.     Arsenic  Poisoning  (Legge)      3-14 

Section       II.     Brass,  Copper(?)  and  Zinc  Poisoning  (Hayhurst).    .    .    .      15-26 

The  Health  of  Brassworkers  (Legge) 27-34 

Section      III.     Carbon  Bisulphide  Poisoning  (Hayhurst) 35-42     , 

Section      IV.     Carbon  Monoxide  Poisoning  (Apfelbach) 43-74  * 

Section        V.    Lead  Poisoning  (Oliver) 75-95 

Early  Diagnosis  of  Lead  Poisoning  (Linenthal) 96-101 

Lead  Poisoning  in  the  United  States  (Hamilton)  ....  102-118 

Section      VI.     Manganese  Poisoning  (Casamajor) 119^125 

Section    VII.     Mercury  Poisoning  (Teleky) 126-135 

Section  VIII.     Naphtha  and  Benzol  Poisoning  (Hamilton) 136-144 

Section      IX.     Chronic  Phosphorus  Poisoning  (Hamilton)    ......  145-152 

Section        X.     The  Prevention  of  Phosphorus  Poisoning  (Andrews)   .    .  153-^57 

CHAPTER       II.    Occup.^tional  Infectious  Diseases 158-186 

—      Section         I.     Anthrax  (Frothingham) 158-172 

Section       II.     Parasites  and  Occupation  (Ashford) 173-186 

CHAPTER      III.     Compressed  Air  Illness  (Erdman) 187-210 

CHAPTER      IV.     Effects     of    Diminished    Atmosphere     upon    Health 

(Kober) 211-217 

DIVISION  II.     SYSTEMIC  OCCUPATIONAL  DISEASES 

CHAPTER         I.     Dust  Diseases  of  the  Lungs  (Oliver) 218-234  \J 

CHAPTER       II.    Diseases  of  the  Blood,  Circulatory  System  and  Kidneys 

(T.  S.Lee) 235-248 

DIVISION  III.     FATIGUE  AND  OCCUPATION.     NEUROSES  '^ 

CHAPTER         I.     Fatigue  and  Occupation  (F.  S.  Lee) 249-269 

CHAPTER       II.     Occupation  Neuroses  (Southard  and  Soloman) 270-295 

DIVISION  IV.     OCCUPATIONAL  AFFECTIONS  OF  THE    NOSE,   MOUTH, 
THROAT,  EYE  AND  EAR 

CHAPTER         I.     Occltp.\tional  Affections   of    the   Nose,   Mouth    ant) 

Throat  (Legge) 296-306' 

xix 


XX  CONTENTS 

Page  | 

CHAPTER       II.     Occupational  Injuries  AND  Diseases  OF  THE  Eye  (Wiirde-  307-330V 

mann)  Glassworkers' Cataract  (Legge) 331-338 

CHAPTER      III.     Injuries  and  Diseases  of  the  E.\r  (Blakej 339-350 

DIVISION  V.     OCCUPATIOX.VL  AFFECTIONS  OF  THE  SKIN.     CANCER  AND 
OCCUPATION.     X-RAY.     RADIUM 

CHAPTER         I.     Occupational  Affections  of  the  Skin  (Bowen) .    .    .    .   351-379 
CHAPTER       II.     Cancer  and  Occupation.     X-ray.     R.adiu^   (Tyzzer  and 

Ordway) '.    .• 380-401 

DIVISION  VI.     ELECTRIC.\L    INJURIES   AND    ELECTRICAL   SHOCK 

(Oliver) 40:1-414 


PART  II 

Etiology  and  Prophylaxis  of  Occupational  Diseases 
Vocational  Hygiene 

DIVISION  I.     ETIOLOGY  AND  PROPH\X.\XIS  OF  OCCUPATIOX.AL  DISEASES 

(Kober) 415-4S4 

DIVISION  II.     VOCATIONAL  HYGIENE.     OCCUPATIONS  INVOLVING 
EXPOSURE   TO    CONDITIONS   INJURIOUS   TO   HE.ALTH   (Kober) 

CHAPTER         I.     Chief  Processes  Involving  Exposure  to  Occupational 

Intoxications 485-570 

Section         I.     Processes    Involving    Exposure    to    Arsenic    Poisoning 

(Kober) 4S5-490 

Section        II.     Processes  Involving  Exposure  to  Brass,  Copper(?),  Zinc 

and  Other  Poisoning  (Kober  and  Hayhurst) 401-504 

Section      III.     Processes    Involving    Exposure    to   Carbon    Bisulphide  >v 
and  Other  Intoxications  in  the  India  Rubber  Industry 

(Kober  and  Hayhurst) 505-511 

Section      IV.     Processes  Involving  Exposure  to  Lead  Poisoning  (KoberV    512-520 
Section        V.     Processes  Involving   P^xposure   to  Mercurial  Poisoning 

(Teleky  and  Kober) 521-534 

Section      VI.     Processes  Involving  Exposure  to  Poisoning  from  Chem- 
icals, Including  Benzol  and  Naphtha  (Kober) 535-5 "o 

CHAPTER       II.     Chief  Processes  In\'olving  Exposure  to  Occupational 
Infectious  Diseases.     The  Hide,  Tanning  ant)  Allied 

Industries  ^ober) 571-579 

CHAPTER      III.     Thj-:  Jewelry  and  Allied  Industries  (Kober)  580-585 

CHAPTER       IV.     Iron,  Steel  and  Allied  Indi'Stries  (Kober)    .    .  5S6-608 

CHAPTFR  V.  The  Printing  and  Publishing  Industry  (Kober)  .  .  609-617 
CHAPTER  Vr.  Mining  and  Quarrying  and  Allied  Industries  (Kober).  618-642 
CHAPTER     \II.    The  Button,  Horn,  Celluloid  and  Allied  Industries 

(Kober) 643-646 

CHAPTER   N'ill.     The  Textile  and  .\llik.d  Industries  (Kober and  Hanson).   647-656 


CONTENTS 


XXI 


Page 

CHAPTER      IX.     The  Boot  and  Shoe  Industry  (Kober) 657-659 

CHAPTER  X.  Tailors,  Garment  and  Laundry  Workers.  (Kober)  .  .  660-665 
CHAPTER  XL  The  Rag,  Shoddy  and  Paper  Industry  (Kober)  .  .  .  666-669 
CHAPTER    Xll.     Farmers,   Gardeners,  Planters    and    Farm  Laborers 

(Kober) 670-672 

CHAPTER  XIII.     The  Lumber  Industry  (Kober) 673-678 

CHAPTER  XIV.     Occupations  Involving  Exposure  to  the  Inhalation  or 

Organic  Gases,  Etc.  (Kober) 679-683 

CHAPTER     XV.     The  Industry  of  Food  Stuffs,  Etc.  (Kober) 684-701 

CHx\PTER  XVI.     Liberal  Professions,  Etc.  (Kober) 702-719 

List  of  Industrial  Poisons 720-739 

List  of  Industries  and  Processes  in  which  Poisoning 

may  Occur 740-748 

Occupational  Mortality  and   Morbity   Statistics  .    .   749-761 


PART  III 

The  Relation  of  Clinics,  Statistics,  Governmental  Stujdy 
and  Legislation  to  Occupational  Diseases 

DIVISION  I.     THE  FUNCTION  OF  CLINICS  IN  THE  PREVENTION  OF 
OCCUPATIONAL  DISEASES 

The  Milan  Clinic  for  Occupational  Diseases  (Devoto) .    765-776 


DIVISION  II.     STATISTICAL   STUDIES   RELATING  TO   OCCUPATIONAL 

DISEASES 


\J 


CHAPTER         I.     Mortality   from   Pulmonary  Tuberculosis  in  Dusty 

Occupations  (Hoffman) 777-788 

CHAPTER       II.     The  Use  and  the  Fallacies  of  Statistics  (Whipple)    .   789-801 

DIVISION  III.    LEGISLATION    AND    GOVERNMENTAL    STUDY    FOR    THE 
PREVENTION  OF  OCCUPATIONAL  DISEASES 

CHAPTER  I.  Methods  and  Scope  of  Legislation  (Andrews)  ....  802-819 
CHAPTER  II.  The  Notification  of  Occupational  Diseases  (Trask)  .  820-830 
CHAPTER      III.     The  Protection  and  the  Promotion  of  Women  Wage 

Earners  (Irene  Osgood  Andrews) 831-846 

CHAPTER      IV.     The  Exclusion  of  Minors  from  Injurious  and  Danger- 
ous Occupations  (Lovejoy)      847-854 

CHAPTER        V.     The  Work  of  Labor  and  Health  Boards  and  of  Legis- 
lative Commissions  (Henderson) 855-866 

CHAPTER      VI.     Effective  Legislation  AND  Administration  (Crownhart) .   867-875 

Index  of  Authors  . 877 

Index  of  Subjects     893 


/ 


PART  I 

SPECIFIC  AND  SYSTEMIC  DISEASES  OF  OCCUPATION 


DIVISION  I 
Specific  Occupational  Diseases 

CHAPTER  I 
OCCUPATIONAL  INTOXICATIONS 

SECTION  I 
ARSENIC  POISONING 

BV  T.  M.  LEGGE,  M.  D.,  London,  England. 

Industrial  arsenic  poisoning  occurs  in  two  distinct  ways:  (i)  from  the 
dust  of  salts  of  arsenic,  through  inhalation  or  contact;  and  (2)  from  arseni- 
uretted  hydrogen  gas. 

The  principal  poisonous  salt  is  white  arsenic,  or  arsenious  acid  (AS2O3). 

Pure  metallic  arsenic  (As)  is  considered  to  be  innocuous. 

Arsenic:  How  Obtained;  Its  Important  Uses. — In  order  to  obtain 
white  arsenic  (arsenious  acid)  the  ore  is  roasted  and  the  arsenic  so  vola- 
tilized is  collected  in  flues  and  chambers.  This  so-called  "arsenic  soot," 
in  the  collection  of  which  elaborate  precautions  in  the  shape  of  overalls 
and  respirators  are  necessary  to  guard  against  the  effects  on  the  skin,  is 
again  submitted  to  heat  in  a  refining  furnace  and  the  fumes  again  de- 
posited in  flues  as  white  as  a  "hound's  tooth."  Subsequently,  the  material 
is  ground  and  packed  in  barrels  usually  by  automatic  arrangements  prevent- 
ing dust.  Use  of  emerald,  Paris  or  Schweinfurt  green  (aceto-arsenite  of 
copper,  Cu(C2H302)2Cu3As206)  depends  on  its  value  as  an  insecticide  in 
preserving  fruit  trees.  In  its  manufacture  the  workers  run  little  risk  until 
the  precipitate  of  emerald  green  (made  by  mixing  solutions  of  arsenite  of  soda 
with  sulphate  of  copper)  is  dried.  All  subsequent  processes  of  sifting  and 
packing,  unless  carried  on  in  closed-in  apparatus  from  start  to  finish,  cause 
the  greatest  distress  to  the  workers,  owing  to  the  very  irritant  nature  of  the 
excessively  fine  and  light  dust  which  "flies"  readily. 

Use  of  Scheele's  green  (arsenite  of  copper)  in  the  preparation  of  artificial 
flowers  and  wall  papers  has  only  a  historical  interest  because  aniline 
colors  have  almost  entirely  taken  the  place  of  arsenic  in  their  manufacture, 
and  a  host  of  other  articles  (notably  children's  toys),  as  a  consequence  of  the 
injury  traced  to  their  action  several  years  ago.  When  arsenic  colors  were 
used,  as  much  as  from  i  to  50  or  60  grains  was  found  per  square  foot  in  differ- 
ent samples  of  wall  papers  examined  for  a  committee  of  the  Medical  Society 
of  London.  The  progress  made  since  then  is  well  illustrated  in  a  Report  of 
the  United  States  Department  of  Agriculture  in  1904,  following  on  the  law 

3 


4  OCCUPATIONAL   INTOXICATIOT^S 

passed  in  1900  by  the  State  Legislature  of  Massachusetts  limiting  the  amount 
of  arsenic  in  wall  papers  and  woven  fabrics,  other  than  dress  goods,  to  o.io 
grain  per  square  yard,  and  in  dress  goods  and  articles  of  dress  to  o.oi  grain 
per  square  yard.  Thus,  of  537  samples  of  paper  examined  only  four  contained 
more  than  o.io  grain  per  square  yard  and  90  per  cent,  of  them  contained  less 
than  0.046  grain.  The  importance  of  the  matter  in  relation  to  wall  papers 
is  that  symptoms  of  coryza  and  conjunctivitis,  gastro-intqstinal  catarrh  and 
obscure  nervous  symptoms,  all  suggesting  arsenical  poisoning,  are  found  to  be 
associated  with  residence  in  rooms  the  wall  papers  of  which  contain  arsenic. 
How  the  arsenic  came  to  be  disengaged  from  such  papers  remained  a  mystery 
until  it  was  discovered  that  certain  moulds  and  fungi  (notably  penicillium 
brevicaule)  while  growing  upon  the  adhesive  paste  split  up  the  arsenic  com- 
pounds, liberating  them  in  the  form  of  a  gas,  di-ethyl-arsine  (AsHETa). 
Thus  technical  improvement  in  processes  due  to  progress  in  chemical  knowl- 
edge is  shown  in  the  case  of  arsenic  colors.  In  some  of  the  aniline  colors 
themselves,  as  of  fuchsin  red,  the  use  of  arsenious  acid  in  the  original  method 
of  manufacture  has  been  dispensed  with  by  adoption  of  the  nitrobenzene 
process. 

In  its  effects  on  the  workers  by  reason  of  the  lightness  and  readiness  of  the 
dust  to  "fly,"  manufacture  of  sheep-dip — a  mixture  of  solutions  containing 
white  arsenic,  caustic  potash  or  soda  to  which  flowers  of  sulphur  are  added — 
closely  resembles  that  of  emerald  green. 

Other  important  uses  of  arsenic  are  of  the  oxide  as  a  preservative  of  hides, 
skins  and  furs,  and  of  red  orpiment  (AS2S2)  as  a  depilatory  in  tanyards. 
After  the  liming  process  the  hides  are  pasted  (on  the  flesh  side)  with  a  mixture 
of  the  red  arsenic  and  lime.  About  5  lb.  of  arsenic  and  a  bushel  of  lime  are 
mixed  to  a  thin  paste  with  water  in  a  tub  and  the  mixture  applied  to  the  hides 
with  a  piece  of  sacking  tied  to  the  end  of  a  pole.  Each  hide,  after  pasting,  is 
folded  once,  and  the  hides  are  then  piled  in  heaps  for  about  1 2  hours,  when  the 
depilatory  action  is  sufficiently  advanced  to  allow  of  removal  of  the  hair  by 
scraping  the  hair  side  of  the  hides  on  the  beam.  In  191 2  three  men  employed 
at  the  London  docks  suffered  from  sharp  attacks  of  sore  throat  and  diarrhea  as 
a  result  of  unpacking  bird  skins.  From  seven  of  the  boxes  it  was  stated  that 
16  lb.  of  arsenious  acid  were  recovered. 

Salts  of  Arsenic. — In  the  form  of  the  salts  arsenic  acts  as  a  local  irri- 
tant or  escharotic  on  such  portions  of  the  skin  or  mucous  membrane  as  it 
may  alight,  wherefs  absorbed  as  a  gas  it  acts  hemolytically,  destroying 
the  red  blood  corpuscles  and  throwing  the  luMiu)glol)in  into  the  blood 
stream. 

If  poisons  are  described  as  (i)  having  a  superficial  action  on  the  skin,  (2) 
being  absorbed  by  the  blood,  changing  its  constituticni,  and  (3)  having  an 
internal,  remote  effect  after  absorption  on  organs  or  tissues  such  as  the  heart 
or  nervous  system,  then  arsenic,  in  a  way  in  which  no  other  substance  does, 
displays  all  three  modes  of  action. 


ARSENIC   POISONING  5 

Symptoms. — The  symptoms  caused  by  dust  of  salts  of  arsenic  show 
themselves  on  the  skin,  on  the  mucous  membrane  of  the  upper  air  passages, 
and  in  the  gastro-intestinal  tract.  Dust  alighting  and  remaining  on  the  skin, 
especially  where  there  are  folds  as  around  the  nose  and  mouth,  or  where  sur- 
faces are  moist  as  in  the  armpits  or  on  the  scrotum,  sets  up  an  acneiform 
eruption  or  an  eczematous  condition  which,  if  not  treated,  will  lead  to 
extensive  ulceration.  Indeed  the  discomfort  produced  by  this  so-called 
"  arsenic  pock  "  is  very  great.  On  the  other  hand,  a  slow  undermining  of  the 
health  such  as  is  commonly  caused  by  lead  poisoning  is  not  evident.  Asso- 
ciated with  the  skin  eruption  are  conjunctivitis  with  oedema  of  the  evelids, 
coryza,  injection  with  dryness  and  soreness  of  the  throat,  hoarseness  (a 
very  noticeable  symptom),  and  depression.  In  severe  cases  the  gastric 
symptoms  become  pronounced — vomiting,  abdominal  cramp,  and  purging. 
In  former  years  workers  were  known  to  be  sometimes  so  seriously  col- 
lapsed as  the  result  of  the  cramps  as  to  require  removal  to  their  homes  in 
cabs. 

Peripheral  neuritis  showing  itself  in  paraesthesia  and  anaesthesia  ("pins 
and  needles"  feeling)  is  much  commoner  in  my  experience  than  paralysis 
of  the  muscles  of  the  extremities. 

Brown  pigmentation  of  the  skin  is  present  in  those  who  have  worked 
for  years  in  contact  with  arsenical  dust.  In  slight  cases  it  is  seen  best  on 
the  upper  and  lower  eyelids,  round  the  temples,  on  the  neck,  the  areolae  of 
the  nipples  and  in  the  folds  of  the  axillae,  while  in  marked  cases  there  may  be 
an  intense  bronzing  of  the  chest,  abdomen  and  back. 

The  most  characteristic  lesion  produced  on  the  upper  air  passages  is 
perforation  of  the  septum  of  the  nose  varying  in  extent  from  a  circular  hole 
^  to  I  in.  in  diameter.  Perforation  may  be  complete  in  a  month  from  the 
time  of  commencement  of  work.  The  anterior  and  lower  margins  of  the 
cartilage,  and  the  bones  to  which  they  are  attached,  never  become  involved 
in  the  ulcerative  process  so  that  deformity  is  absent,  thus  distinguishing  the 
condition  easily  from  that  due  to  s\T)hihs.  Once  the  perforation  is  complete 
no  further  inconvenience  is  felt;  not  a  few  of  the  workers  are  ignorant  of  the 
existence  of  the  condition. 

Sir  Jonathan  Hutchinson  has  laid  stress  on  what  he  beheves  to  be  rela- 
tively frequent  occurrence  of  cancer  in  those  who  have  taken  arsenic 
for  long  periods.  A  list  of  31  published  cases  collected  by  Pye-Smith 
includes  two  in  which  the  persons  had  been  employed  in  a  sheep-dip 
factory. 

The  following  table  shows  the  number  of  cases  of  arsenical  poisoning 
(other  than  those  due  to  arseniuretted  hydrogen)  reported  to  the  Chief 
Inspector  of  Factories,  London,  during  the  years  1900-1913  inclusive  and 
their  distribution  according  to  industry: 


6  OCCUPATIONAL   INTOXICATION'S 

Industry  Total  cases 

Manufacture  of  emerald  green 46 

Extraction  of  arsenic 8 

Manufacture  of  sheep-dip 5 

Paint  and  color  works 4 

Chemical  works 3 

Smelting  of  metals  (lead,  copper) 3 

Sorting  bird  skins 3 

Wall  paper  manufacture 2 

Shot  making i 

Scraping  paint  off  ship i 

Tanning i 

Unloading  white  arsenic i 

Indefinite 8 

Total  86 

The  symptoms  described  are  those  which  inevitably  result  from  the 
manufacture  of,  or  contact  with,  the  dust  of  salts  of  arsenic  where  hand 
labor  is  relied  upon,  even  when  protection  is  sought  by  the  usual  precautions 
of  the  wearing  of  overalls  and  respirators,  locally  applied  exhaust  ventila- 
tion, washing  and  bath  accommodation  and  periodical  medical  examination. 
Fortunately  progress  in  adoption  of  automatic  methods  involving  no  hand- 
ling of  the  materials  in  a  dusty  condition  has  robbed  the  emerald  green 
industry  of  danger.  Thus,  in  a  large  factory  where  this  has  been  achieved  I 
examined  25  workers  in  1900  of  whom  20  had  worked  for  3  months  or  less 
(a  short  duration  of  employment  generally  signifies  an  unpleasant  occupa- 
tion with  unskilled  labor  ignorant  of  the  risk)  and  found  only  two  free  from 
signs  of  the  discomfort  and  injury  caused.  As  late  as  the  year  1908  out  of 
an  average  of  33  workers  examined  weekly  5.4  per  cent,  had  to  be  suspended, 
as  compared  with  0.6  per  cent,  in  1913,  the  weekly  average  exposed  to  risk 
having  been  reduced  to  14,  owing  to  the  improvements  effected  in  the  process. 
The  dried  material  is  here  placed  in  an  enclosed  hopper  connected  with  a 
powerful  exhaust  fan.  When  the  door  is  shut  the  material  is  tipped  over 
into  a  receptacle  from  which  it  is  elevated  into  a  sieve  (also  under  negative 
pressure)  and  from  there  again  passed  automatically  by  means  of  a  worm 
into  the  packing  hopper  and  so  into  the  tin  canisters.  Only  as  the  green 
falls  into  the  cans  is  there  possible  exposure  to  dust,  and  the  man  i)lacing  the 
cans  in  position  is  completely  protected  by  the  exhaust  draught  immediately 
behind  them.  No  dust  is  visible  from  start  to  fmish — a  condition  very 
different  from  that  of  a  few  years  ago  when  the  effect  of  the  dust  on  the  eyes 
and  nose  made  one  glad  to  get  out  of  the  atmosphere  after  5  minutes.  Splen- 
did washing  accommodation  and  douche  baths  now  make  the  conditions 
wholly  satisfactory.  At  the  same  time  the  wise  precaution  of  periodic 
medical  examination  at  weekly  intervals  has  not  been  relaxeil. 

In  the  process  of  de-arsenicating  sulphuric  acid  a  large  alkali  works  have 
issued  tin-  following  notice  of  precautions  to  be  observed  by  their  workmen: 


ARSENIC   POISONING 


ARSENIC  RECOVERY  PROCESS 


7 


Whereas  Arsenic  is  a  powerful  Poison,  it  is  very  important  that  the  great- 
est possible  care  should  be  taken  by  all  who  are  engaged  in  its  manufacture  or 
brought  in  contact  with  it.  The  Ofl&cials  and  Workmen  are,  therefore,  re- 
quested to  strictly  observe  the  following  Rules,  and  generally  to  take  every 
precaution  to  prevent  Arsenical  Poisoning: 

1.  In  the  process  of  De-arsenicating  Vitriol,  care  must  be  taken  to  main- 
tain an  in-draught  in  the  pipes  and  apparatus,  to  prevent  the  escape  of  Arsen- 
ical Fumes,  and  should  an  escape  be  observed,  the  Brine  (or  Hydrochloric 
Acid)  should  be  at  once  shut  off  until  the  defect  is  remedied. 

2.  In  the  Precipitating,  Drying  and  Packing  operations,  a  clean  Respirator 
(Grell's  improved  pattern)  must  always  be  used.  A  clean  one  must  be 
obtained  every  morning  from  the  Laboratory,  and  the  one  used  the  previous 
day  returned  to  the  Laboratory  to  be  cleansed  and  prepared  for  use  the  next  day. 

3.  Every  workman  engaged  in  this  process  shall  be  prov-ided  by  the 
Company  with  a  pair  of  India-rubber  Gloves  and  a  suit  of  Clothes,  which  he 
is  to  put  on  in  the  morning  and  remove  on  leaving  the  works  at  night,  and 
shall  take  a  bath  before  putting  on  his  ordinary  clothing.  These  special 
clothes  to  be  washed  by  the  Company  and  supplied  clean  to  the  workman 
once  a  week.  Workmen  must  thoroughly  wash  their  hands  before  taking 
food  in  the  Works. 

4.  The  buildings  in  which  the  manufacture  of  Arsenic  is  carried  on  must 
be  well  ventilated  to  remove  all  fumes  of  Chloride  of  Arsenic  or  dust  of 
Arsenious  Acid  from  the  atmosphere. 

5.  Any  workman  having  cuts  or  abrasions  on  the  skin  will  not  be  per- 
mitted to  work  in  the  Arsenical  Department  until  such  wounds  have  quite 
healed. 

6.  Any  workman  showing  the  slightest  signs  of  Arsenical  Poisoning  must 
be  examined  by  a  Doctor  and  undergo  medical  treatment. 

Arseniuretted  hydrogen  gas,  the  extraordinary  subtle  poisoning,  occurs 
mainly  in  the  chemical  metalliferous  industries,  but  occasionally  isolated 
cases  will  naturally  occur  in  any  chemical  action  of  acid  on  metal  when  either 
one  or  both  are  arseniferous.  The  workman,  therefore,  absorbs  the  poison 
in  operations  in  which  as  a  rule  the  possibility  of  poisoning  is  not  so  much  as 
imagined.  Fortunately  this  form  of  poisoning  is  rare.  Such  cases  as  have 
come  to  my  knowledge  have  been  frequently  due  to  work  carried  on  in  con- 
fined spaces  or  where  the  means  for  the  removal  of  the  gases  evolved  were 
inadequate. 

The  following  table  shows  the  number  of  cases  reported  by  medical 
practitioners  to  the  Chief  Inspector  of  Factories  in  the  years  1900-19 13  and 
the  industries  in  which  they  occurred: 

Industry  Cases 

Chemical  works 20 

Galvanizing  works 7 

Bullion  refining 2 

Bronzing  of  art  metal 2 

Paper  manufacture i 

Tin-plate  works _ i 

Total 33 


6  OCCUPATIONAL    INTOXICATIONS 

Professor  John  Glaister  of  Glasgow  in  his  interesting  monograph  on  this 
form  of  poisoning  has  classified  120  cases  as  follows: 

I.  Chemical  operations  in  laboratories    8 

(a)  Operations  with  known  arseniferous  materials i 

(b)  Operations  with  unknown  arseniferous  materials 14 

(c)  Operation  not  known 7 

II.  Trade   processes 73 

III.  Military  ballooning 16 

IV.  Domestic  environment  (wall  papers)  ....     * 6 

V.  Causes   not  known 2 

Total J  20 

The  professions  and  occupations  exposed  to  risk  are  classified  thus: 

I.  Professional  chemists:  (a)  medico-legal  analyses  in  cases  of  arsenical 
poisoning;  (b)  in  preparation  of  AsHs  for  demonstration  purposes;  (c) 
researches  in  aniline  colors  and  in  arsenical  compounds. 

II.  Physicists  and  physiologists,  from  inhalation  of  arseniferous  hydrogen  in 
experiments  on  the  voice  or  as  to  pulmonary  capacity,  or  other  like 
experiments. 

III.  Workers  in  aniline  colors,  from  preparation  of  arsenic  acid  (a  process  now 
obsolete). 

IV.  Chemical  workers:  (a)  manufacture  of  iron  sulphate;  (6)  manufacture 
of  zinc  chloride  and  sulphate;  (c)  zinc  smelting;  (d)  roasting  and 
extraction  of  mineral  ores;  (e)  manufacture  of  bleaching  powder  (cal- 
cium hypochlorite);  (/)  manufacture  of  soda  sulphate  by  treatment 
of  soda-lye  with  arseniferous  sulphuric  acid. 

V.  Ballooning  for  military  and  other  purposes. 

VI.  Plumbers  in  brazing  operations. 
VII.  Galvanizers. 

The  essential  factor  for  the  production  of  arseniuretted  hydrogen  gas  is 
the  presence  of  nascent  hydrogen  in  solutions  containing  arsenic;  hence  its 
occurrence  when  hydrogen  is  generated  from  zinc,  tin,  copper,  or  iron,  and 
sulphuric  or  hydrochloric  acid  when  either  or  both  show  a  proportion  of 
arsenic.  These  substances  and  the  acids,  unless  the  sulphuric  acid  has  been 
prepared  from  sublimed  sulphur  or  has  undergone  a  de-arsenicating  process, 
are  always  more  or  less  contaminated.  Samples  of  sulphuric  acid  have  been 
found  to  contain  proportions  of  arsenious  acid  varying  from  as  high  as  0.045 
to  0.140  per  cent,  and  hydrochloric  acid  from  0.0014  to  o.Oqi  per  cent. 
Some  of  the  cases  among  chemists,  as,  for  instance,  of  Gmclin  who  discovered 
the  gas,  have  followed  the  mere  snifling  to  detect  its  garlicky  smell. 

Symptoms.  —The  symi)toms  set  in  generally  a  few  hours  after  inhalation 
of  arseniuretted  hydrogen  gas,  with  nausea  and  sickness  quickly  followed  by 
almost  continuous  vomiting.  Jaundice  of  the  skin  and  conjunctiva*  comes  on 
in  the  course  of  48  hours  and  assumes  in  all  but  very  slight  cases  an  intense 
coppery  hue;  there  is  pain  in  the  region  of  the  li\tr,  and  hemoglobinuria  or 
hematuria,  and  in  the  severest  cases  sui)pri'ssion  oi  urine.     All  these  s\nip- 


ARSENIC   POISONING  9 

toms  are  referable  to  the  hemolytic  action  of  the  gas  upon  the  red  blood  cells 
which  are  thereby  rendered  incapable  of  supplying  the  coloring  matter 
necessary  for  the  internal  respiration  of  the  organs  and  so  cause  a  condition 
of  tissue  suffocation.  The  functions  of  the  liver  and  kidneys  break  down  in 
the  effort  to  eliminate  the  products  of  the  disintegrated  corpuscles.  The 
characteristic  jaundice  is  explained  far  more  readily  on  the  supposition  that 
the  dissolved  hemoglobin  circulating  in  the  blood  impregnates  the  tissues 
and  thus  communicates  to  them  the  peculiar  color  than  that  the  liver,  as  a 
consequence  of  the  abnormal  condition  of  the  blood  reaching  it,  secretes  an 
abnormal  bile  rich  in  bile  pigment.  The  jaundice  is,  therefore,  hematogenous 
and  not  hepatogenous. 

After  the  discoloration  of  the  skin  the  most  characteristic  signs  post- 
mortem are  seen  in  the  kidneys,  which  are  described  as  brown,  chocolate 
brown,  or  brownish  black;  there  is  enlargement  and  the  tubules  are  full  of 
casts  of  broken-down  corpuscles. 

Several  of  the  cases  enumerated  in  the  list  of  reported  cases  occurred  in 
groups.  Reference  to  some  of  them  will  serve  to  illustrate  the  circumstances 
under  which  nascent  hydrogen  was  generated  in  arseniferous  solutions  and 
the  kind  of  precautions  which  should  be  carried  out  in  chemical  works  where 
there  is  risk  of  evolution  of  the  gas.  In  some  instances  knowledge  of  them 
only  slowly  filtered  through  in  consequence  of  the  bizarre  symptoms  of  jaun- 
dice suggesting  yellow  fever,  acute  yellow  atrophy  of  the  liver,  or  acute 
phosphorus  poisoning.     Doubtless  some  cases  are  never  recognized. 

In  a  works  for  the  manufacture  of  bleaching  powder  a  man  engaged  in 
the  cleaning  out  of  a  Weldon  chlorine  still  at  the  usual  three  weekly  period 
was  reported  as  suffering  from  "constant  vomiting,  coppery  jaundice,  livid- 
ity  of  the  body,  the  mucous  membrane  of  the  Hps  almost  black,  suppression 
of  urine — what  little  was  drawn  off  consisting  almost  of  blood. "  He  died 
6  days  afterward.  It  transpired  that  a  fellow-workman  was  affected  in 
the  same  way  though  less  severely,  and  that  a  few  months  previously  an  othe 
man  had  died  after  a  similar  cleaning  operation.  Of  such  stills  there  are 
throughout  the  country  several  thousands,  and  as  no  other  cases  were  re- 
corded there  had  obviously  been  unusual  circumstances  at  work.  The  still 
in  question  differed  from  most  similar  stills  in  not  having  a  trap-door  at  the 
base  through  which  the  residue  could  be  discharged  outside.  Instead  the 
residue  was  placed  in  a  bucket  and  drawn  out  through  the  manhole  above. 
The  Weldon  mud — acid  calcium  manganite — is  run  into  the  still  which  is 
then  filled  to  a  height  of  2  ft.  with  hydrochloric  acid.  After  the  chlorine  has 
been  evolved  the  manganese  chloride  liquor  is  withdrawn,  but  a  certain 
amount  of  residue  remains  behind.  A  probable  source  for  the  production  of 
the  gas  lay  in  the  hydrochloric  acid  made  on  the  premises  from  pyrites.  The 
deceased  had  used  a  new  galvanized  iron  bucket  and  iron  shovel  for  the  re- 
moval of  the  residue.  A  sample  of  the  liquid  containing  the  deposit  was  found 
to  contain  0.45  per  cent,  of  arsenic  acid  and  the  hydrochloric  acid  used  0.292 


10  OCCUPATIONAL   INTOXICATIONS 

per  cent,  of  arsenious  acid.  This  the  analyst  described  as  "highly arsenical," 
It  evolved,  when  iron  and  zinc  was  placed  in  it,  arseniuretted  hydrogen  rap- 
idly and  abundantly.  This  acid  I  find  to  be  very  much  more  arsenical  than 
the  crude  acids  of  commerce.  Similar  he  said  that  to  immerse  zinc  or  iron 
implements  in  the  liquid  containing  the  deposit  in  an  imperfectly  ventilated 
still  would  involve  great  risk  to  life.  In  ii  oz.  of  the  viscera  which  had  been 
preserved  in  formaldehyde  (equivalent  to  about  24  oz.  of  fresh  viscera) 
M50  grain  (0.0028)  arsenicum  was  found  and  on  this  the  analyst  reported 
that  "assuming  the  arsenic  was  uniformly  distributed  through  the  body,  and 
that  the  deceased  was  a  man  of  average  height,  the  whole  body  would  have 
contained  0.28  grain  (rather  more  than  a  quarter  of  a  grain)  arsenicum.  One 
and  a  half  grains  of  arsenicum  in  the  form  of  white  arsenic  taken  by  the  mouth, 
has  caused  the  death  of  an  adult,  and  less  than  half  that  amount  has,  in  my 
experience  brought  life  into  great  peril;  2  cu.  in.  of  arseniuretted  hydrogen  gas 
contains  i}^  grains  arsenicum.  Arsenic  is  quickly  eliminated  in  the  excre- 
tions. I  am  of  opinion  that  the  presence  of  arsenic  in  the  viscera  is  quite 
consistent  with  death  from  arsenic,  the  man  having  survived  2  days."  To 
render  occurrence  of  another  such  fatality  impossible  the  firm  took  steps  to 
substitute  wooden  utensils  in  the  cleaning  out  of  the  stills  for  the  metal  ones 
previously  used. 

A  few  months  later  10  cases  of  poisoning  by  AsHs  were  reported  in  the 
manufacture  of  zinc  chloride.  Zinc  oxide — the  waste  from  galvanizing  pots — 
was  treated  with  hydrochloric  acid  made  on  the  premises  in  a  vat  situated  in 
open  air  upon  a  platform.  To  protect  the  men  from  the  weather  a  lean-to 
roof  had  recently  been  erected  about  10  yd.  away  from  the  vat  above  a  gang- 
way along  which  the  workmen  wheeled  the  barrows  of  zinc  oxide  waste. 
This  shelter  played  an  unexpectedly  important  part  in  influencing  the  poi- 
soning. On  the  occasion  in  question  the  men  were  eager  to  get  through  a 
certain  amount  of  work  by  noon.  The  day  was  warm  and  unusually  sultry. 
The  fumes  must  have  been  drawn  in  the  direction  of  the  shelter  by  the  in- 
draught of  a  furnace  situated  in  the  building  against  which  it  was  placed. 
The  men  working  nearest  to  the  vat  itself  suffered  least  of  all;  those  in  a  well 
under  the  vat  most;  but  seven  men  engaged  in  shovelling  from  a  cart  and 
never  at  any  time  within  10  yd.  of  the  vat  all  suffered  more  or  less  severely, 
one  dying  on  the  seventh  day  after.  The  hydrochloric  acid  admittedly 
contained  arsenic.  Very  decided  information  was  obtained  by  Dr.  Clayton 
of  Accrington,  who  investigated  the  cases  that  others  had  previously 
occurred  from  time  to  time. 

A  similar  case  was  reported  in  the  manufacture  of  zinc  sulphate  in  an 
uncovered  vat  in  the  open  air  which  had  only  been  used  experimentally  a  few 
times.  Subsequently  the  process  was  removed  to  a  position  whence  all  fumes 
could  be  conveyed  to  the  main  chimney  stack.  The  necessity  of  carrying 
away  gases  likely  to  contain  AsHs  into  the  main  chimney  stack  is  emphasized 
by  Dr.  Dixon  Mann  after  an  investigation  of  five  cases  arising  from  the  manu- 


ARSENIC   POISONING  II 

facture  of  zinc  chloride.  The  sulphuric  acid  contained  0.309  per  cent,  of 
metallic  arsenic. 

Galvanizing  is  a  process  where  cases  of  AsHs  poisoning  might  be  expected 
in  view  of  the  quantities  of  commercial  hydrochloric  acid  and  zinc  and  iron 
used.  Reported  cases,  however,  are  few.  Seven  cases  with  indefinite  symp- 
toms of  headache,  giddiness,  sickness,  weakness  of  the  limbs  and  tremor  hav- 
ing been  notified,  I  visited  the  factory.  The  acute  symptoms  had  passed 
oflF,  but  I  satisfied  myself  that  jaundice  and  hematuria  had  been  present  in 
some  while  others  showed  keratosis  of  the  skin  on  the  hands  resembling  the 
condition  seen  in  poisoning  from  arsenic  in  beer.  The  only  men  who  had 
been  attacked  were  those  engaged  in  dipping  the  iron  sheets  in  the  acid  solu- 
tion. The  amount  of  arsenic  in  the  acid  used  was  stated  to  have  been  0.035 
per  cent. — a  rather  small  amount  to  account  for  the  cases. 

In  the  year  191 2  an  Inspector  of  Factories  was  summoned  by  telegram 
from  the  proprietor  of  a  paper  works  who  stated  that  a  workman  had  been 
seized  with  symptoms  resembling  yellow  fever.  His  work  was  to  dissolve 
block  tin  after  granulation  in  strong  hydrochloric  acid.  After  the  pots  were 
charged,  steam  was  turned  on  to  raise  the  mixture  to  boiling  point.  When 
solution  was  completed  the  pots  stood  for  12  hours  to  cool  and  the  contents 
were  then  ladled  out.  During  this  last  operation  some  gas  was  disengaged. 
The  symptoms  were  typical — jaundice  and  hematuria.  Samples  of  the  acid, 
tin  and  zinc,  and  a  sample  of  the  urine  also,  6  oz.,  were  submitted  to  the  Gov- 
ernment Laboratory  for  analysis.  The  results  as  to  the  proportions  of 
arsenic  calculated  as  arsenious  oxide  were  as  follows: 

Liquor  from  preparation  bath  Practically  nil. 

Sheet  zinc  Practically  nil. 

Block  tin  0.03  per  cent. 

Feathered  tin  0.05  per  cent. 

Precipitated  tin  o.oii  per  cent. 

Strong  hydrochloric  acid  0.20  per  cent,  or  159  grains  per  gallon. 

Urine  0.07  grains  per  gallon. 

The  proportions  of  arsenic  in  the  samples  of  block  and  feathered  tin  are 
those  usually  found  in  commercial  tin,  but  the  quantity  in  the  hydrochloric 
acid  is  very  high.  The  absence  of  arsenic  in  the  preparation  bath  liquor 
(tin  solution)  indicates  that  the  arsenic  is  given  off  in  the  form  of  gas  or 
vapor  during  the  process  of  solution  of  the  tin  in  the  acid,  and  direct  ex- 
periments with  the  samples  have  shown  that  considerable  quantities  of 
arseniuretted  hydrogen  are  evolved  in  this  way.  It  is  probable  that  most 
of  the  arsenic  is  given  off  as  arseniuretted  hydrogen.  Assuming  the  samples 
to  represent  the  materials  generally  used,  the  total  amount  of  arsenic  (cal- 
culated as  arsenious  oxide)  evolved  during  each  operation  in  which  132  gal. 
of  acid  are  used  is  3  lb.,  equivalent  to  upward  of  10  cu.  ft.  of  arseniuretted 
hydrogen. 

The  amount  of  the  arsenic  (0.07  grains  per  gallon)  found  in  the  sample  of 


12  OCCUPATIONAL   INTOXICATIONS 

urine  is  much  higher  than  that  normally  present  in  men  employed  in  alkali 
works  who  may  be  supposed  to  run  the  chance  of  slight  absorption  and  in 
whom  the  amount  has  been  found  to  vary  from  o.ooii  to  0.0035  grain  per 
gallon.  At  the  works  in  question  there  were  700  earthenware  vessels  used 
in  the  room  where  the  tin  foil  was  extracted  and  fan  ventilation  was  installed 
at  the  opposite  end  of  the  room  to  that  where  there  are  two  open  doors. 
Question  of  discontinuing  the  process  altogether  was  under  consideration. 
Use  of  de-arsenicated  acid  would  remove  the  possibility  of  such  accidents  and 
should  be  pressed.  Three  cases  occurred  in  a  process  for  the  recovery  of 
copper,  the  men  attacked  being  employed  at  the  time  in  emptying  vitriol 
from  the  depositing  tanks.  A  fatal  case  was  that  of  a  man  employed  in  a 
poorly  ventilated  room  in  dipping  "store  plates"  composed  of  zinc  with  a 
small  proportion  of  copper  into  a  "bronzing"  solution — essentially  a  solution 
of  the  chlorides  of  arsenic  and  iron  dissolved  in  strong  hydrochloric  acid — 
to  give  the  appearance  known  as  "art  metal." 

Treatment.— The  only  form  of  treatment  holding  out  any  hope  of  suc- 
cess for  the  inhalation  of  arseniuretted  hydrogen  gas  is  prolonged  inhala- 
tion of  oxygen.  Where  there  are  facilities  in  a  hospital,  transfusion  of  blood 
from  the  artery  of  the  giver  into  the  vein  of  the  sufferer  and  saline  injec- 
tions have  been  advocated. 

Arsenical  Poisoning  from  Consumption  of  Beer  and  Other  Articles. 
— Brief  note  should  be  made  of  the  circumstances  attending  outbreaks  of 
arsenical  poisoning  from  consumption  of  beer  and  other  articles.  On  this 
subject  the  Report  of  the  Royal  Commission  in  England  and  Wales  in  1901, 
following  on  the  epidemic  mainly  in  Manchester,  Salford  and  Liverpool 
which  affected  certainly  6000  persons  of  whom  at  least  70  died,  has  given 
valuable  data.  The  disease  was  characterized  by  paralysis  and  wasting  of 
certain  muscles,  principally  those  of  the  extremities,  and  derangement  of 
function  in  certain  sensory  nerves,  closely  resembling  in  these  respects  the 
peripheral  neuritis  associated  with  alcoholic  poisoning.  In  addition,  a  great 
proportion  of  the  cases  exhibited  various  affections  of  the  skin,  such  as  ery- 
themata,  herpes,  pigmentation,  bullae.  In  some  the  alcoholic  type  pre- 
dominated and  in  others  the  arsenical.  Beer  contaminated  with  arsenic 
was  accountable  for  all  the  symptoms.  Analysis  of  some  samples  yielded 
as  much  as  13-^  grains  per  gallon  but  usually  the  proportion  found  was  from 
I  to  }/'2,  to  }?4:  of  a  grain  per  gallon  or  less.  The  introduction  of  arsenic  into  the 
beer-:was  made  in  the  form  of  "brewing  sugars" — glucose  and  "invert 
sugar" — which  are  extensively  used  as  adjuncts  to,  or  partial  substitutes  of, 
malt,  and  as  "priming"  solutions  added  after  the  fermentation  of  the  wort. 
But  both  the  glucose  and  the  invert  sugar  derived  their  arsenical  contamina- 
tion from  the  acid  used  in  preparing  the  former  from  starch  and  the  latter 
from  cane  sugar.  In  the  acid,  responsible  for  the  majority  of  the  cases,  as 
much  as  1.45  to  1.9  per  cent,  of  arsenious  acid  was  detected.  Sulph«UEJ« 
acid  made  from  brimstone,  or  in  the  usual  way  after  a  de-arsenicating  process 


ARSENIC    POISONING  I3 

effectively  applied,  may  be  practically  arsenic  free.  This  is  not  the  only  way, 
however,  in  which  arsenic  may  contaminate  beer.  It  may  be  introduced 
with  the  malt  as  the  result  of  the  arsenic  in  the  coal  or  coke  burnt  in  the  dry- 
ing of  the  malt.  WTien  the  fuel  is  burnt  the  arsenic  is  volatilized  and  be- 
comes deposited  as  arsenious  acid  on  the  surfaces  of  the  kiln.  Part  remains 
in  the  ash  and  this  also,  if  carried  up  by  a  draught  of  air,  may  settle  on  the 
malt.  As  bearing  on  this,  six  remarkable  cases  of  arsenical  poisoning  caused 
by  fumes  from  a  coke  stove  in  an  ironing  room  of  a  laundry  have  interest. 
Vomiting  and  loss  of  power  in  the  legs — in  one  case  almost  complete  paralysis 
of  them  with  complete  paraesthesia  below  the  knees,  and  loss  of  patellar  and 
plantar  reflexes — were  the  prominent  signs  without  any  changes  in  the  skin. 
Two  leaky  coke  stoves  were  used  to  heat  the  irons  and  while  no  carbonic 
oxide  could  be  detected  in  samples  of  the  air  of  the  room  there  was  a  notice- 
able proportion  of  sulphur  dioxide.  The  analyst  suggested  that  as  sulphur 
dioxide  was  present  in  the  coke  used  arsenic  was  present  also.  He  found 
H4  grain  per  pound  (o.ooi  per  cent.).  Arsenic  was  detected  in  the  urine 
of  the  two  worst  cases.  Since  coal  only  has  been  used  in  the  stoves  and  leak- 
age thus  readily  detected,  there  has  been  no  more  trouble. 

The  Royal  Commission  recommended  that  no  substance  should  be  used 
as  an  ingredient  of  food  which  contains  a  larger  proportion  of  arsenic  than 
/lOO  grain  per  pound,  or,  in  the  use  of  solutions,  Hoo  grain  per  gallon. 

The  amounts  of  arsenic  likely  to  be  found  in  the  urine  during  life  or  in  the 
viscera  post-mertem  in  cases  of  suspected  industrial  poisoning  by  arsenic  are  so 
small  that,  for  its  detection,  recourse  must  be  had  to  comparison  of  mirrors 
obtained  preferably  by  the  Marsh-Berzelius  method  after  the  material  to  be 
examined  has  been  subjected  to  appropriate  treatment  by  which  any  arsenic 
present  is  obtained  in  a  solution  suitable  for  the  proper  application  of  the 
test.  By  its  means  the  Royal  Commission  state  in  their  report  that  arsenic 
will  be  detected  in  amounts  well  below  Hooo  grain  per  pound  or  (in 
the  case  of  a  liquid)  well  below  3^300  grain  per  gallon.  For  an  account 
of  this  method  as  also  of  the  other  recognized  tests — Reinsch,  Marsh 
and  Gutzeit — reference  must  necessarily  be  made  to  standard  works  on 
toxicology. 

An  interesting  point  elucidated  by  the  Royal  Commission,  and  one  of 
great  value  in  obtaining  indication  of  the  past  history  of  a  patient  in  regard  to 
arsenic,  was  the  fact  that  persons  taking  comparatively  small  quantities  of 
arsenic  habitually  excrete  the  poison  in  their  hair  to  an  extent  readily  appre- 
ciable by  chemical  tests.  Thus  men  taking  3  minims  of  liquor  arsenicalis 
three  times  a  day  (about  ^{0  grain  of  arsenic  daily)  at  the  end  of  2  months 
showed  amounts  of  arsenic  varying  from  3^20  grain  to  I5  grain  per  pound 
in  hair  which  had  grown  during  the  interval,  whereas  out  of  a  total  of  41  con- 
trol cases  the  hair  of  38  was  either  free  from  arsenic  or  showed  no  more  than 
M50  grain  of  arsenic  per  pound  of  hair. 


14  OCCUPATIONAL    INTOXICATIONS 


REFERENCES 


Annual  Reports  of  the  Chief  Inspector  of  Factories,  1899-1914. 

First  and  Final  Report  and  Minutes  of  Evidence  of  the  Royal  Commission  on  Arsenical 

Poisoning  from  Beer  and  other  Articles.     Eyre  &  Spottiswoode,  1903. 
"Poisoning  by  Arseniuretted  Hydrogen  or  Hydrogen  Arsenic,"  by  John  Glaister,  M.  D., 

F.  R.  S.,  Ed.  E.  &  S.  Livingstone,  1908. 
"Industrial  Poisoning."     J.  Rambousek.     (Translated  by  T.  M.  Legge)  E  Arnold,  1913. 
"An  Investigation  as  to  the  Danger  of  Poisoning  from  Lead  and  Arsenic  in  Industries  outside 

Greater  New  York,"  by  C.  T.  Graham-Rogers,  M.  D.,  and  John  H.  Vogt,  B.  S. 

(containing  a  suggested  code  of  regulations  and  bibliography).     J.  B.  Lyon  Com- 
pany, Albany. 
Sir  T.  Oliver  in  Albutt  and  Rolleston's  System  of  ^Medicine.     Vol.  II,  Part  i.     ^lacmillan 

&  Co.,  1906. 
"Arsenic  in  Paper  and  Fabrics,"  by  J.  K.  Haywood  and  H.  J.  Warmer,  U.  S.  Department  of 

Agriculture  Bulletin  86,  1904. 
"Arsenic  Cancer,"  by  R.  J.  Pye-Smith,  Lancer,  Vol.  H,  page  210,  1913. 
"Arsenic  Medicine  and  Toxicology"  by  J.  Dixon  Mann,  M.  D.     C.  Griffin  &  Co.,  London. 


SECTION  II 
BRASS,  COPPER(?),  AND  ZINC  POISONING 

BY  E.  R.  HAYHURST,  M.  D..  Columbus,  Ohio. 

Copper  and  zinc,  at  least  in  toxic  forms,  are  so  infinitely  bound  up  with 
the  brass  industry  that  it  is  well  to  consider  them  in  this  relation.  The  found- 
ing and  casting  industry  in  general  is  divided  into  two  great  divisions — iron 
and  brass.  Although  the  processes,  except  the  manner  of  melting  metals, 
are  quite  identical,  still  managements  and  tradesmen  remain  quite  distinct. 
The  brass  worker,  however,  has  an  acquaintance  with  a  great  many  more  met- 
als and  alloys  than  the  iron  worker. 

While  nearly  all  metals  may  enter  the  brass  crucible,  copper  and  zinc  are 
the  primary  ones  and,  with  tin,  constitute  the  ternary  metals. 

COPPER 

Copper  is  mined  extensively  in  various  parts  of  the  world,  particularly  the 
United  States,  China,  Japan,  the  Ural  Mountains  and  Sweden.  It  is  prac- 
tically the  only  metal  which  occurs  pure,^  as  in  the  Lake  Superior  region. 
Usually  it  is  in  the  form  of  various  ores.  The  copper  mines  of  the  United 
States  produce  half  of  the  world's  product  and  employ  over  53,000  men. 
The  richest  centers  are  Montana  and  Arizona,  but  Michigan  mines  employ 
the  most  men.^  California  and  Utah  are  also  important  centers.  Copper  is 
worth  in  normal  times  about  15  cts.  per  pound.  Copper  melts  at  io8o°C., 
which  is  3So°C.  higher  than  the  point  where  zinc  becomes  a  gas.  Copper 
assumes  a  gaseous  form  at  something  over  i3oo°C. 

Literature  is  replete  with  references  to  the  relative  harmlessness  of  copper 
upon  the  human  organism.  Certain  vegetable  organisms  are  extremely  sensi- 
tive to  the  poisonous  action  of  copper  and  its  salts.  Experimentally,  it  causes 
chronic  poisoning,  when  given  in  large  amounts  to  animals.^  It  certainly  has 
little  significance  as  an  industrial  poison.  "Copperman's  chest"*  is  a  pul- 
monary fibrosis,  due  purely  to  mechanical  irritation.  "Copper  colic"  and 
the  rare  cases  of  polyneuritis,  afifecting  especially  the  lower  limbs,  reported^ 
as  occurring  among  brass  polishers  and  coppersmiths  and  even  those  pre- 
sumably working  with  pure  copper,  are  rare  complaints  considering  the 
large  numbers  so  employed,  and  are  probably  due  to  lead,^  arsenic,  heat- 
fatigue  toxins''  or  other  factors. 

Copper  dust,  or  alloys  rich  in  copper,  generally  produce  in  workers  green- 
stained  hair,  greenish  deposits  on  the  teeth  and  in  the  gums,  and  a  green  tint 
to  the  perspiration,  which  may  persist  even  after  a  thorough  bath,  while  the 


1 6  OCCUPATIONAL   INTOXICATIONS 

skin  may  be  actually  bronzed.  With  the  exception  of  sore  gums  and,  per- 
haps, pyorrhea  (these  are  both  rare),  the  effects  of  all  these  upon  the  health 
are  remote.  Copper  has  been  found  accumulated*  in  all  of  the  organs  of  the 
body,  in  the  various  excretions,  and  in  the  bones  of  former  copper  Workers, 
which  have  shown  a  green  color  when  subsequently  removed  from  graves. 
Dogs  fed  copper  pass  it  on  to  the  suckling  young,  ^  in  whose  livers  it  may  be 
found,  without  apparent  effect.  While  not  a  normal  constituent  of  the 
human  body,  copper  is  found  in  the  liver  in  practically  all  autopsies  be- 
cause of  the  manifold  opportunities  of  the  human  being  to  ingest  copper.  ^° 

Workers  in  various  copper  processes  are  often  thought  to  be  "copper 
poisoned."  While  copper  miners  have  various  afflictions,  none  can  be  charged 
to  any  peculiar  toxicity  of  copper  itself.  Zadek's^^  tables  show  that  copper- 
smiths suffer  above  the  average  in  most  forms  of  sickness,  but  he  discounte- 
nances copper  poisoning.  Seventy-five  coppersmiths  interviewed  in  Chicago^^ 
were  uniformly  healthy  men,  some  of  whom  had  been  at  the  trade  as  long  as 
40  years.  There  was  no  evidence  of  "copper  poisoning"  among  bronze  or 
copper  founders. 

In  copper  smelting,  sulphuric  and  other  fumes  must  be  acknowledged  as 
obnoxious  and  very  destructive  to  surrounding  vegetation.  In  order  to  obvi- 
ate this,  very  high  chimneys  are  resorted  to  (one  at  Boston  is  500  ft.  high). 
The  toxic  vapors  which  escape  from  the  electrolytic  refining  of  copper  (an 
important  American  industry)  are  acidic  in  character,  and  cannot  be  con- 
sidered as  copper  poisoning.  While  copper  volatilizes  to  a  slight  extent  be- 
low its  boiling  point  (probably  the  surface  temperature  of  the  molten  mass 
actually  reaches  above  the  boiling  point),  the  metal  is  rarely  boiled,  as  is  zinc, 
in  any  industrial  process.  In  an  instance  in  which  this  did  occur  (electric 
I  furnace), ^^  those  who  inhaled  the  vapors  suffered  from  severe  influenzal-like 
symptoms,  quite  similar  to  those  experienced  after  inhaling  zinc  fumes. 
Perhaps  the  severe  symptoms  experienced  by  those  who  breathe  the  fumes 
arising  from  pots  of  German  silver  (copper  60,  zinc  24,  nickel  16)  are  due  to 
some  extent  to  volatilized  copper,  as  well  as  to  zinc,  since  the  melting  point 
of  nickel  (i5oo°C.)  is  above  the  boiling  point  of  copper.  Certain  salts  of 
copper  are  astringent,  or  even' caustic,  and,  in  chemical  industries  and  copper 
plating,  may  produce  contact  poisoning.  The  idea  that  copper  workers  are 
immune  to  typhoid  fever  was  exploded  30  years  ago. 

ZINC 

Zinc  occurs  in  nature  principally  as  the  carbonate  (calamine),  sulphide 
(blende),  and  silicate.  Its  ores  are  widely  distributed.^  It  was  first  smelted 
in  England  in  1743,  in  Europe  in  1807,  and  in  the  United  States  in  1873. 
The  United  States  led  all  other  countries  in  191 1  with  nearly  3,000,000  tons 
production.  The  American  industry  engages  over  21,000  men  (igio),^ 
or  2  per  cent,  of  all  miners,  and  is  increasing  at  the  rate  of   20  per   cent. 


BRASS,    COPPER^?),    AND    ZINC    POISONING  1 7 

annually.  Smelting  is  usually  done  in  the  nearest  coal  districts.  The  West- 
ern ores  contain^  lead,  iron,  cadmium,  and  occasionally  arsenic.  The  New 
Jersey  ores  are  free  from  arsenic,  practically  so  from  lead,  but  contain  man- 
ganese.* The  price  of  zinc,  or  "  spelter,"  keeps  at  about  5  cts.  per  pound,  and 
is  controlled  by  an  international  syndicate.^  Since  the  onset  of  the  European 
war  it  has  been  quoted  as  high  as  373-^  cts.  Zinc  melts  at  4i7.6°C.  and 
boils  at  73o°C. ;  hence  it  is,  with  the  exception  of  cadmium,  the  only  supposedly 
innocent  metal  boiling  under  iooo°C.,  an  important  point  to  remember  since 
metal  workers  are  thus  industrially  liable  to  the  volatilization  products  of 
but  one  metal — zinc.  In  fact  zinc  volatilizes  at  temperatures  as  low  as  5oo°C.® 
similar  to  the  well-known  evaporation  of  water  at  temperatures  far  short  of 
its  boiling  point.  The  use  of  chlorides  (as  in  galvanizing)  still  further  pro- 
motes the  volatilization  of  zinc.  It  is  important  to  remember  that  all  metals 
distill  to  a  limited  degree  far  below  their  boiling  points,  and  if  the  metal  is 
intrinsically  poisonous  its  mere  molten  condition  becomes  a  health  hazard, 
which  increases  with  temperature.  Lead,  for  instance,  distills  even  more 
readily  than  zinc,  although  its  boiling  point  is  900°C.  higher. 

Zinc  is  the  most  wasted  of  all  metals.'  It  is  also  the  most  impure  of  all 
metals  used  industrially  and,  on  this  account,  retains  its  old  name  "spelter."^ 
There  is  usually  present  a  trace  of  lead  (less  than  o.i  per  cent.)  as  well  as  iron, 
and  sometimes  manganese,  cadmium  and  arsenic.  But  these  impurities  are 
very  rarely  the  cause  of  industrial  poisoning.  Plumbism  in  this  relation  is 
usually  due  to  the  fact  that  lead  is  subsequently  added  to  spelter  alloys. 

Tests  for  Zinc. — Qualitatively  Ganassini's^  test  is  very  delicate.  The 
substance  to  be  tested,  preferably  in  the  form  of  zinc  sulphide  or  calcium 
zincate,  is  exposed  for  a  moment  to  the  fumes  of  boihng  hydrochloric  acid 
arising  from  a  test  tube.  The  substance  is  then  heated  briefly  to  drive  off 
chlorine  fumes.  A  uric  acid  reagent  is  made  by  dissolving  2  grams  of  uric 
acid  in  loo  cc.  of  5  per  cent.  KOH.  Streak  the  substance  with  this  reagent, 
using  a  fine  glass  filament.  Then  touch  the  moistened  streak  with  a  crystal 
of  K  sFeCne,  or  with  a  freshly  prepared  10  per  cent,  solution  of  the  same.  In  a 
moment  a  beautiful  azure-green  color  will  appear.  Avoid  excess  of  the  uric 
acid  reagent.  In  verifying  test  reagents  try  them  directly  upon  a  piece  of 
zinc  or  galvanized  iron.  Slight  modifications  render  the  test  still  more 
delicate  and  micro-chemical  in  character.  The  test  may  be  applied  directly 
to  washed  mucous  membranes  and  sections  of  organs.  The  most. delicate 
quantitative  test^''  is  the  calcium  zincate  method  which,  however,  is  a  little 
too  extended  for  the  general  practitioner.  Its  delicacy  is  claimed  to  be  one 
in  30,000,000  parts,  even  in  the  presence  of  other  metals  and  salts. 

Principal  Uses  of  Zinc. — Zinc  has  the  following  principal  uses  from  the 
sanitarian's  viewpoint:  (i)  Processes  involving  the  use  of  brass  and  bronze 
alloys;  (2)  galvanizing;  (3)  manufacture  of  German  silver  and  white  metal; 
and  (4)  the  use  of  zinc  oxide  (zinc  white),  used  especially  in  the  rubber  and 
paint  industries  and  the  handling  of  zinc  salts.     Other  uses  of  zinc  are  as 


16  •       OCCUPATIONAL   INTOXICATIONS 

lithopone,  a  lead  substitute  in  paints  and  enamels;  in  the  manufacture  of  oil- 
cloth; the  manufacture  of  galvanic  battery  plates;  the  de-silverization  of 
lead;  etching  and  lithographing  plates;  and  the  manufacture  of  parchment 
paper. 

Toxicity  of  Zinc. — Zinc  per  se  is  non-poisonous.^^  In  this,  practically  all 
recent  authorities  are  agreed.  Michaelis^^  claims  zinc  to  be  a  normal  con- 
stituent of  human  tissues  (probably  in  very  minute  quantities).  Zinc  exists 
in  a  large  number  of  plants  in  which  it  probably  has  a  definite  physiological 
function. ^^  In  animal  tissues,  zinc  causes  precipitation  in  unusual  dilution,^* 
forming  an  inert(?)  albuminate.  Zinc  ions  markedly  activate  metabolic 
processes.  1^  When  taken  internally,  zinc  as  oxide  or  salt  can  be  detected  in 
the  blood  and  practically  all  tissues  of  the  body.^^  Given  subcutaneously, 
the  same  obtains.  Zinc  does  not  accumulate  to  any  extent  in  the  system, 
but  it  is  stored  temporarily  in  the  liver  and  is  found  in  the  bile,  urine,  milk 
and  other  excretions.  As  with  other  metals,  it  is  more  largely  excreted  by 
the  intestines,  and  perhaps  the  stomach,  than  by  the  kidneys. ^'^  Zinc  albu- 
minate does  not  affect  red  corpuscles  nor  other  tissues,  except  possibly  the 
heart  muscle  (frogs). ^^ 

Certain  salts  of  zinc,  as  the  sulphate  and  chloride,  are  well-known  astrin- 
gents and  caustics,  but  industrial  poisoning  (dermatitis,  conjunctivitis) 
occurs  from  these  only  as  the  result  of  carelessness  in  their  handling.  In 
their  manufacture  arsenic  poisoning  may  occur  from  impurities.  Zinc 
chloride  is  used  for  denaturing  alcohol,  as  a  preservant  for  wood,  for  preparing 
parchment  paper,  and  for  weighting  goods.  The  fumes  of  zinc  chloride 
which  form  in  soldering  zinc,  previously  cleansed  with  hydrochloric  acid,  are 
an  occasional  complaint  (proteid  resorption  poisoning  ?).  Zinc  sulphate  is 
used  in  varnishes  and  as  a  mordant  for  the  production  of  colors  on  calico. 
It  is  also  applied  with  a  brush,  in  saturated  solution,  to  plaster  and  cement 
surfaces  as  a  preparation  for  subsequent  painting. 

But  there  is  something  which  occurs  in  association  with  the  immediate 
products  of  zinc  fumes  which  causes  acute  intoxication.  Molten  zinc  when 
slightly  overheated  produces  a  greenish-yellow  flame,  and  yields  to  the  air  a 
whitish  smoke,  composed  of  the  flaky  oxide  of  zinc  ("philosopher's  wool"). 
This  is  usually  encountered  in  the  making  and  pouring  of  brass.  There  is 
also  produced  some  zinc  dust,  due  to  incomplete  oxidation.  Obviously  the 
fumes  themselves,  being  at  high  temperature,  cannot  be  inhaled  or  at  least 
absorbed  as  such.  Experimentally,  zinc  dust,  zinc  oxide  and  zinc  car- 
bonate are  all  harmless, ^^  whether  ingested  or  inhaled.  Lehmann,^°  how- 
ever, proved  that  the  symptom-complex  known  as  " brassfounders'  ague" 
could  be  produced  in  every  feature  in  man  by  burning  pure  zinc  and  inhaling 
the  oxide  therefrom.  He  believes  that  the  zinc  oxide  produces  proteid 
destruction  in  the  respiratory  membranes  with  resorption  of  the  destroyed 
cell  contents  into  the  system,  and  that  these  dead  proteids  acting  as  toxal- 
bumens  produce  the  symptoms.     Experimental  animals  do  not  develop  the 


BRASS,    C0PPER(?),    AND   ZINC   POISONING  1 9 

same  symptoms,  but  after  such  exposure  show  a  more  or  less  violent  conges- 
tion and  reddening  of  the  respiratory  mucous  membranes  with  zinc  demon- 
strable in  the  lung  tissues  and,  later,  in  various  organs  (guinea-pigs  and 
rabbits). ^^  To  our  mind,  the  phenomenon  is  best  explained  as  due  to  the 
hygroscopic  action  of  the  oxide  (or  zinc  carbonyl,  ZnC04)22  in  the  hot  foundry 
atmosphere.  Thus  the  usually  inert  oxide  not  only  dries  but  actually  sears 
the  epithelium  (cihated,  simple  and  parenchymatous)  of  the  respiratory 
mucous  membranes.  An  analogy  is  seen  in  the  fact  that  zinc  chloride  may 
even  carbonize  organic  substances  in  its  demand  for  moisture,  and  the 
resultant  symptoms  (as  seen  in  intra-uterine  cauterizations^^  with  zinc 
chloride)  are  similar  to,  and  also  explainable  as,proteid  resorption  phenomena. 
There  are  many  things  in  the  composite  picture  of  "zinc  ague"  which  tend 
to  bear  out  the  above  explanation:  (i)  Pharmacologists  have  pro\4en  the 
harmlessness  of  non-caustic  zinc  compounds;^^  (2)  the  quick  immunity  to 
subsequent  attacks,  which  is  similar  to  all  foreign-proteid  poisonings;  (3) 
no  poisonous  metal  is  known  to  produce  a  rise  in  temperature;  (4)  metallic 
poisons  act  accumulatively;  (5)  infection  is  negatived  since  ulcerations, 
septicemia,  pyemia,  and  fatalities  never  occur;  (6)  fumes  of  other  metals, 
whether  such  metals  are  poisonous  or  not  per  se,  produce  similar  symptoms 
(copper,^^  nickel, ^^  iron,^^  cobalt,^^  cadmium'^);  (7)  that  the  symptoms  are 
associated  with  zinc  (or  brass)  only  is  simply  a  trade-process  circumstance, 
due  to  the  low  boiling  point,  excessive  volatility,  cheapness  and  therefore 
waste  of  zinc  to  the  air. 

ZmC  AGUE 

Synonyms. — Brassfounders'  ague,  brass  chills,  zinc  chills,  smelter  shakes, 
metal  shakes,  zinc  asthma,  braziers'  disease. 

Definition. — "Zinc  ague,"  or  "brassfounders'  ague,"  may  be  defined  as 
an  acute  malaria-like  syndrome  of  chill,  fever  (sometimes)  and  sweat,  ap- 
pearing a  few  hours  after  the  inhalation,  for  a  few  minutes  or  longer,  of  zinc 
fumes,  whether  pure  or,  as  is  the  usual  rule,  in  the  form  of  brass  fumes,  af- 
fecting only,  or  mostly,  those  unaccustomed  to  such  exposure;  further  char- 
acterized by  the  development  of  a  form  of  temporary  immunity,  and  absence 
of  immediate  serious  or  fatal  consequence.  Definite  chronic  symptoms  due 
to  the  presence  of  zinc  probably  do  not  occur,  but  the  morbidity  and  mortality 
rates  of  workmen  constantly  exposed  to  the  breathing  of  the  fumes  are  high, 
with  respiratory  diseases  especially  in  evidence. 

Occurrence. — Of  the  different  classes  of  workers,  the  symptoms  of  the 
"ague"  do  not  occur  among  the  miners,  nor  in  the  handling  of  zinc  or  its 
compounds  at  ordinary  temperatures;  they  may  occur,  though  rarely,  among 
galvanizers  and  infrequently  among  zinc  smelterers  and  oxide  makers;  they 
occur  very  commonly  among  workers  in  brass  foundries,  casting  shops  and 
in  brazing  processes,  also  among  refiners  of  junk  metal  and  dross. 


20  OCCUPATIONAL   INTOXICATIONS 

Symptoms. — At  the  end  of  a  few  hours'  exposure,  or  even  less,  to  the 
breathing  of  the  metallic  smoke  which  arises  during  the  melting  or  pouring 
of  brass  or  zinc,  the  nose,  throat  and  substernal  region  have  a  sensation  of 
dryness,  soreness  and  burning.  The  conjunctivae  feel  irritated.  There  may 
be  a  metallic  taste  in  the  mouth,  an  unproductive  cough,  a  feeling  of  constric- 
tion in  the  chest,  lassitude,  headache  and  loss  of  appetite,  followed  sometimes 
by  nausea  and  vomiting.  Within  one  to  several  hours  after  the  exposure 
the  vision  may  become  blurred,  the  headache  worse,  the  cough  more  produce 
tive  and  the  sputum  blood-streaked.^"  Chilly  sensations  begin  to  appear 
and  the  victim  usually  takes  to  his  bed.  The  shivering  rapidly  increases  into 
a  distinct  rigor,  which  may  last  from  }-2  to  2  or  3  hours.  No  amount  of 
external  heat  or  friction  appears  to  lessen  the  chill  and  shaking.  There  is  a 
great  desire  to  imbibe  hot  drinks  and  stimulants.  During  this  stage  there 
are  usually  muscular  cramps  and  sharp  joint  pains.  The  victim  feels  that 
he  is  deathly  sick.  These  symptoms  end  almost  by  crisis  and  are  followed 
by  a  most  profuse  perspiration,  in  which  some  claim  there  is  an  odor  of  zinc. 
There  is  an  immediate  sensation  of  great  relief.  Sleep  supervenes  and  the 
victim  awakens  the  next  morning  with  no  remaining  symptoms  of  his  recent 
experience  other  than  a  little  exhaustion,  perhaps  a  metallic  taste,  and  a 
temporary  loathing  of  food.  The  entire  attack  lasts  from  a  few  to  20  hours, 
seldom  longer. 

In  many  cases  there  is  a  distinct  rise  in  temperature  during  and  following 
the  chill,  but  it  is  not  constant  and  may  be  subnormal.  It  does  not  usually 
mount  high.  The  pulse  during  the  chill  is  small  and  rapid — 120  to  130  per 
minute  (zinc  effect  upon  the  heart  ?).  The  respiratory  rate  is  not  much  af- 
fected. The  blood  findings  during  and  after  a  chill  have  been  reported  as 
normal,  although  some  have  found  a  slight  leucocytosis,  and  Arnstein,^^  in 
experiments  with  brass  fumes  on  men,  found  a  constant  leucocytosis  to 
16,000,  in  which  neither  the  per  cent,  of  lymphocytes  nor  of  eosinophiles  was 
affected,  thus  differing  from  an  infection.  SigeP-  proved  the  absence  of 
carbon  monoxide  hemoglobin  as  an  etiological  factor  by  spectroscopic  ex- 
amination of  the  blood.  The  urine  after  a  severe  chill  invariably  shows 
albumen  and  casts  which  clear  up  within  a  day  or  so,  and  zinc  is  usually 
present,  although  much  more  of  this  metal  is  to  be  found  in  the  feces.  Arn- 
stein  was  struck  by  the  fact  that  these  symptoms  were  evoked  by  very  minute 
traces  of  zinc  in  the  air  (0.007  gram  of  zinc  oxide  in  30  liters  of  air).  Graeve^^ 
reports  an  enlargement  of  the  spleen  noticeable  after  a  few  days. 

There  are  many  conditions  which  seem  to  influence  the  onset  and  severity 
of  zinc  chills.  The  newer  workmen,  or  those  who  have  returned  to  work 
after  a  week's  vacation,  perhaps  only  after  a  day  or  so  off,  as  over  Sunday, 
are  the  most  liable.  Unless  the  exposure  to  the  metallic  smoke  and  vapors 
has  been  unduly  severe,  the  workman  continues  at  his  vocation  all  day  with- 
out noticing  untoward  health  effects.  It  is  usually  after  leaving  work  at 
night  that  the  sickness  comes  on.     Manv  state  that  as  soon  as  the  cold  out- 


BRASS,    COPPER (?),    AND    ZINC    POISONING  21 

side  air  strikes  them  or  when  removing  the  clothes  at  bedtime  the  chill  is 
inaugurated.  Hence  chills  are  far  more  common  in  winter  than  in  summer. 
This  seasonable  influence  is  due  mostly,  however,  to  decreased  ventilation 
through  closing  of  doors,  windows  and  skylights  in  foundries.  Following 
a  snowstorm,  such  a  large  per  cent,  of  workers  have  been  seized  with  chills 
that  the  condition  has  been  mistaken  for  an  epidemic  of  some  form.  The 
worst  complaints  in  my  experience  have  come  from  so-called  bronze  foundries 
where  journals  are  cast  for  car  wheels.  Although  the  bronze  contains  only 
a  small  per  cent,  of  zinc,  it  is  melted  and  poured  by  the  ton  so  that  the  amount 
of  fumes  becomes  excessive.  Lead  poisoning  from  babbitting  is  very  frequent 
here  too.  The  chills  occur  rarely  in  shops  where  pouring  is  done  but  once  or 
twice  daily.  The  frequency  of  the  chill,  other  conditions  remaining  the  same, 
is  almost  in  direct  ratio  to  the  percentage  of  zinc  contained  in  the  alloy. 
Furnace  men,  casters  and  helpers  are  rather  more  exposed  than  moulders. 
Deep  breathing  while  under  strain  is  a  most  important  factor.  About  70 
to  80  per  cent,  only  of  workmen  seem  susceptible;  hence  some  natural  im- 
munity seems  to  exist.  Also  a  tolerance  occurs  in  about  70  to  75  per  cent, 
of  workmen  who  work  steadily  at  the  trade.  A  further  20  to  25  per  cent, 
sicken  more  or  less  regularly,  but  usually  not  severely.  Only  in  very  rare 
cases  do  these  attacks  occur  so  frequently  that  a  change  of  occupation  is 
necessary.  Still  many  older  workmen  prefer  to  lay  off  in  the  winter  season. 
The  workers  consider  the  chills  so  commonplace  and  matter-of-course  that 
they  do  not  go  or  send  to  the  physician  on  account  of  them.  All  factors 
which  tend  to  lower  natural  vitality  are  predisposing  to  zinc  chills,  especially 
alcoholism, ^^  poor  quality  of  food,  as  is  consumed  by  a  large  proportion  of 
the  foreign  workmen,  irregular  hours,  and  excesses  of  all  kinds.  In  addition, 
weak,  anaemic  individuals,  young  persons  and  women  are  more  subject  to 
zinc  fumes  than  are  robust  individuals. 

Unlike  lead,  zinc  does  not  produce  chronic  poisoning.  This  is  best 
explained  by  the  fact  that  it  has  very  little  tendency  to  accumulate  in  the 
system.  The  chronic  neuritic  symptoms,  described  by  older  writers  as 
affecting  the  lower  extremities  particularly,  were  quite  probably  due  to 
impurities  in  the  metals,  such  as  arsenic  and  lead.  However,  the  continual 
occurrence  of  zinc  chills  produces,  in  from  5  to  20  years'  time,  the  same  re- 
sults as  described  below  in  brass  poisoning.  (The  morbidity  and  mortal- 
ity statistics  of  zinc  workers  are  considered  under  the  special  industries  in 
Part  II.) 

Diagnosis. — As  just  stated,  the  physician  must  get  away  from  the  idea 
of  attempting  to  diagnose  chronic  zinc  or  brass  poisoning,  as  there  is  no  such 
condition.  Look  to  lead,  arsenic  or  manganese  for  the  specific  causes  of 
such  conditions.  Every  complaint  of  chill,  fever  and  sweat,  lasting  a  few 
hours'  time,  and  with  absence  of  interval  symptoms  should  cause  inquiry 
to  be  made  as  to  exposure  to  metal  fumes,  the  more  so  if  the  symptoms  occur 
after  the  work  period,  or  during  inclement  weather,  or  the  winter  season. 


2  2  OCCUPATIONAL   INTOXICATIONS 

The  worker  himself  may  consider  the  symptoms  due  to  malaria,  especially 
if  he  has  ever  been  so  afiflicted.  Zinc  ague  attacks  must  be  differentiated 
from  influenza,  or  la  grippe,  as  there  is  respiratory  complaint,  aches  and 
pains,  and  a  subfebrile  movement  in  all  three,  but  the  "ague"  shows  a  mini- 
mal character  of  catarrhal  symptoms  with  pain,  soreness  and  constriction 
symptoms  in  the  throat  and  substernum  prominent.  The  chills  are  usually 
unduly  severe,  while  the  recovery  from  subsequent  malaise  after  the  sweating 
period  is  quick,  and  there  is  an  entire  absence  of  sequellae.  Acute  bronchitis, 
onset  of  tonsillitis,  or  of  septic  processes  may  confuse  for  the  first  few  hours. 
The  repetition  of  the  chills  and  fever  of  irregular  type  may  be  confused  with 
the  course  of  tuberculosis,  Hodgkin's  disease  and  leukemia,  while,  on  the 
other  hand,  the  physician  often  comes  to  the  erroneous  conclusion,  particu- 
larly if  no  fever  can  be  detected,  that  he  is  dealing  with  a  case  of  neurasthenia, 
hysteria,  or  malingering. 

BRASS 

Brass  is  an  alloy  of  copper  with  a  base  metal,  usually  zinc,  but  sometimes 
tin,  and  contains  varying  quantities  of  other  metals.  Fine  brass  or  red  brass 
consists  of  copper  2  and  zinc  i.  However,  as  these  two  metals  combine  in 
practically  all  proportions,  many  alloys  are  possible.  " Cheap  yellow  brass" 
is  very  rich  in  zinc.  The  making  of  brass  was  known  to  the  Phoenicians 
before  Solomon's  time,  Pliny  describes  brass  fumes.  The  brass  of  the  Bible 
was  probably  bronze.  From  }4,  to  13  per  cent,  of  lead  is  contained  in  brass 
alloys. 

Bronze  is  an  alloy  consisting  of  copper  9  and  tin  i.  In  the  industry, 
however,  red  brass  is  very  often  styled  "bronze,"  although  zinc  is  the  other 
component  instead  of  tin.  Many  metals  and  metalloids  are  added  to  brass 
and  bronze  to  convey  certain  physical  properties.  Aluminum,  copper  and 
German  silver  castings  are  other  products.^ 

Usually  scrap  metal  consisting  of  all  sorts  and  compositions  of .  (non- 
ferrous)  metals  makes  up  one-third  or  more  of  the  alloy;  then  copper,  zinc, 
or  lead  ingots  are  added,  to  arrive  at  an  approximate  composition.  Conse- 
quently it  will  be  seen  that  the  brass  manufacturing  industry,  or  more  prop- 
erly the  non-ferruginous  metal-working  trade,  is  engaged  in  the  handling  of 
large  amounts  of  copper,  zinc  and  tin,  while  it  must  not  be  overlooked  that 
lead,  antimony,  nickel,  aluminum,  cadmium,  manganese,  iron,  phosphorus, 
arsenic  and  sulphur  may  enter  the  brass  crucible.  In  subsequent  processes 
of  cleansing,  plating  and  finishing,  dangerous  acids  and  cyanide  solutions 
are  used. 

Pseudo-brass  Poisoning — Wounds  due  to  brass  objects  and  similar 
alloys  arc  of  traumatic  and  infectious  significance  only.  Brass  dust  (grinders, 
polishers  and  buffers)  does  not  produce  "  brassf ounders'  ague,"  and  has  only 
the  harmful  effects  of  metallic  dusts  in  general.  The  lead  in  the  alloy-dust 
may  produce  its  symptoms  in  very  susceptible  persons(?).     Brass  in  any  con- 


BRASS,    C0PPER(?),    AND    ZINC   POISONING 


23 


dition  short  of  the  recent  vaporous  state  of  its  components  produces  no  in- 
toxication peculiar  to  itself. 

The  essential  health-hazard  from  brass  is  the  inhalation  of  the  metallic 
fumes.     Analyses  of  brass  fumes  show: 


Substance 


Deposits  from  flues- 


Analysis  of  fumes' 


Bench'settling* 


Zinc  oxide 

Lead  oxide 

Iron  oxide 

Copper  oxide. . . 
Cadmium  oxide 


32.13      24.74 
0.31        1.92 

2-43    

2.85         2.50 
1.56   I     0.89 


28.82 

0.00 

2.78 

(copper)  I.  7 1 


(zinc)  44.9 
(lead)     0.8 


(moisture)        9 .  64 


Insignificant  traces  of  arsenic,  nickel  and  manganese  may  be  present,  and 
Sigel  found  the  chills  where  copper  was  absent  in  the  fumes.  Symptoms 
traceable  to  phosphorus  in  phosphor-bronze  and  manganese  in  manganese- 
bronze  have  never  been  reported.  Antimony  poisoning  occurs,  however, 
among  type-metal  refiners  and  melters,  and  dermatitis  and  "biting"  naso- 
tracheitis  from  this  should  be  distinguished  from  "brass  itch"  and  "zinc 
asthma"  respectively.  Braziers  and  hard-solder  workers,  especially  where 
electric  welding  or  the  modern  blow  pipes  (oxy-acetylene,  oxy-hydrogen)  are 
used,  may  suffer  greatly  from  metal  chills  due  to  volatilization  of  the  alloys 
worked  upon.^ 

Brass  Poisoning. — " Brassfounders'  ague"  is  the  only  condition  which 
can  be  recognized  under  this  heading  and  this  has  been  described  under  zinc 
where  it  properly  belongs.  The  condition  was  first  mentioned  by  Thackrah 
in  1832,^  who  considered  it  periodic  because  seasonal;  the  zinc  factor  was 
recognized  by  Greenhow^  in  1862;  the  earliest  American  cases  were  cited  by 
Oppenheim^  in  1894,  while  later  references  are  Moyer  and  Lavin,^  also 
Pietrowiecz,^"  Chicago,  1904,  Sicard,^^  New  York,  1905,  and  Hayhurst,^^ 
Illinois,  1910  and  1912. 

Chronic  Effects  of  Brass  Poisoning. — In  Chicago^^  the  fact  that  85 
per  cent,  of  1761  foundry  workers  were  under  40  years  of  age,  and  only  i  per 
cent,  over  50  years,  was  explained  by  employers  as  due  to  "slowing  up," 
or  beginning  increpitude,  and  by  workmen,  as  gradual  incapacitation  from 
the  inhalation  of  brass  fumes  and  the  strain  of  the  work.  The  constant 
intake  and  elimination  of  zinc  from  the  system  along  with  the  repetition 
of  brass  chills  or  the  constantly  forced  immunity  to  the  same  are  enough  to 
cause  degenerative  diseases  in  themselves  even  though  the  immediate 
afflictions  above  mentioned  are  overlooked.  Chronic  bronchitis  or  "asthma," 
emphysema  and  pulmonary  tuberculosis  are  very  common.  Older  workers 
invariably  complain  of   dyspepsia,  "biliousness,"  occasionally  of  gall-stones 


24  OCCUPATIONAL   INTOXICATIONS 

and  they  are  often  icteroid.  Constipation  is  the  rule  among  them  and 
hemorrhoids  are  frequent  complaints.  Pyorrhea  alveolaris,  carious  teeth, 
sallow  complexion  and  anaemia,  ill-nourishment  and  emaciation,  chronic 
alcoholism,  Bright's  disease,  nervous  and  heart  diseases  are  all  above  the 
average." 

Remedial  Measures. — No  specific  treatment  for  zinc  or  brass  ague  has 
been  discovered.  Mild  emetics,  hot  milk,  and  stimulants  are  used.  A  good 
purge  seems  as  beneficial  as  anything.  To  counteract  the  effects  of  the  sub- 
limed fumes  which  are  swallowed  the  drinking  of  milk  before  and  after  pour- 
ing, and  of  water  containing  sodium  bicarbonate,  magnesia  or  lime  water,  is 
recommended.  For  such  as  is  inhaled,  particularly  if  a  chill  is  anticipated,  a 
dose  of  Epsom  or  Glauber  salts  should  be  taken  at  once,  and  to  relieve  the  re- 
spiratory membranes  an  expectorant,  such  as  ammonium  chloride,  combined, 
perhaps,  with  Brown's  mixture.  During  the  course  of  the  chill,  hot  lemonade, 
hot  milk,  hot  milk  with  pepper,  seem  welcomed.  The  use  of  whiskey,  or  any 
alcoholic  liquors  could  be  of  value  only  because  of  their  narcotic  action,  and 
according  to  the  statements  of  the  more  observing  workmen  are  of  no  more 
benefit  nor  relief  than  the  hot  drinks  above  mentioned.  Further,  alcohol 
increases  the  subsequent  malaise,  and  adds  to  the  liability  of  sequellae. 
Alcoholic  beverages  are  especially  to  be  discouraged  because  of  the  develop- 
ment of  industrial  alcoholism,  that  is,  the  worker  who  has  come  to  believe 
that  alcohol  is  a  true  antidote  to  the  metal  fumes,  rapidly  becomes  a  chronic 
alcoholic  as  a  result.  Many  such  cases  are  seen.  This  condition  only 
lays  him  more  liable  than  ever  to  the  "ague."  In  fact  many  workmen  claim 
that  abstainers  are  the  last  to  succumb  to  the  chills,  and  have  them  the 
mildest.  The  prostration  usually  compels  one  to  take  to  bed,  where  plenty 
of  covering  and  external  heat,  especially  to  the  feet,  are  very  comforting. 
Antipyretics  and  antiperiodics  are  useless,  while  the  symptoms  do  not  usually 
warrant  opiates.  Finally,  any  physician  may  consider  himself  lucky  who  has 
been  called  to  see  a  case  of  "zinc  ague"  at  its  height,  especially  in  an  in- 
formed worker,  since  the  victim  usually  knows  what  he  has  got,  and  also 
its  cause,  and  immediate  prognosis,  and  hence  does  not  see  the  need  of  the 
services  of  a  physician.  But  the  physician  will  see  many  cases  of  tuber- 
culosis, pneumonia,  chronic  degenerative  diseases  and  pre-senile  conditions 
if  in  practice  much  among  zinc  or  brass  workers  who  are  concerned  with 
the  hot  processes.     (The  prophylaxis  of  "  zinc  ague  "  is  considered  in  Part  II.) 

REFERENCES 

Copper 

1  Molinari. — General  and  Industrial  Chemistry  (Inorg.),  1913,  has  been  consulted  for  most 

of  the  mineral  and  chemical  statements. 
^  13th  U.  S.  Census  Abstract. 
3  Robert. — Lehrb.  der  Intox.,  1904-1906. 
*  Latimer. — Lancet,  1887,  I,  1126. 


BRASS,    C0PPER(?),    AND    ZINC    POISONING  25 

5  Rohrer. — Klin.  Vortage,  Bd.  I,  Heft  3. 
^Zadek. — Weyl's  Handb.  der  Arbeiterkr.,  1908,  112. 
7  Lee.— Am.  Jr.  Pub.  Hlth.,  Nov.,  191 2,  863. 
^Lewin. — Lehrb.  der  Toxik.,  1897. 

*  Baum.  u.  Seeliger,  Dtsch.  Thierarztl.  Woch.,  1896. 

10  See  Raoult  et  Breton,  Jr.,  de  Pharm.  et  de  Chim.,  1878,  XXVII,  118. 
'1  Reference  6,  above. 

"Hayhurst. — Am.  Jr.  Md.  Sc,  May,  1913,  723-739- 

1'  Hanson. — Metal,  and  Chem.  Eng.,  191 1,  No.  2,  IX,  67. 

Zinc 
^  Ref.  I,  under  Copper. 
2  Ref.  2,  under  Copper. 
^  111.  Comm.  Rep.  on  Occ.  Dis.,  191 1,  74. 

*  Casamajor. — 15th  Int.  Cong,  on  Hyg.  and  Dem.,  Ill,  pt.  2,  574. 
5  Molinari. — Loc.  cit.,  under  Copper. 

^  Bassett. — Jr.  of  Ind.  and  Eng.  Chem.,  March,  191 2,  164. 
^  Parsons. — Jr.  of  Ind.  and  Eng.  Chem.,  March,  191 2,  165. 
s  Encyc.  Brit.,  nth  Ed.,  191 2. 

9  Ganassini. — Bol.  d.  Soc.  Med.  Chir.  di  Pa  via,  1909,  XXIII,  72-90. 
1"  Bertrand  et  Javillier. — Compt.  Rend.  Acad.  d.  Sc.  1907,  CXL,  924-6. 

11  Rambousek. — Industrial  Poisoning,  trans,  by  Legge,  1913,  151. 

12  Michaelis.— Quoted  from  Hill  in  Ref.  Handb.  of  Med.  Sc,  VIII,  339. 
1' Javillier. — Ann.  de  I'lnst.  Past.,  1908,  721. 

1*  Kisskalt. — Ztschr.  f.  Hyg.  u.  Infect.,  1912,  LXXI,  472. 

1=  Knauer. — Ztschr.  f.  med.  Elek.  u.  Rontg.,  Leipzig,  IX,  H.  12,  1907. 

1^  Matzkevvitch  et  al. — Ref.  10,  above. 

^'  Arnstein. — Wien  Arbeit,  a.  d.  Gebiete  d.  soz.  Med.,  1910,  I,  49-50.     Also  Moore-Older- 

shaw-Wilhams,  Brit.  Med.  Jr.,  Aug.  2,  1913,  217. 
■*  Sacher. — Arbeit,  d.  Pharm.  Instit.  zu  Dorp.,  1893-4,  88-152. 
1^  Sacher. — Loc.  cit.     See  also  Hirt  (1882),  Lehmann  (1910). 
^oLehmann. — Arch.  f.  Hyg.,  1910,  358-381. 
21  Hayhurst. — Ref.  12,  under  Copper. 
^2  We  must  stiU  wait  upon  the  chemist  to  tell  us  exactly  what  the  nature  of  zinc  gas  is,  as  it 

is  inhaled  within  a  few  feet  of  its  source. 
"  Buttersach. — Mntschr.  f.  Geb.  u.  Gyn.,  1909,  XXIX,  11-22.     See  also    Clin.  Mod., 

Zarogoza,  1908,  VII,  343. 
2^  See  also  Lander  and  Edwards,  Jr.  Comp.  Path,  and  Ther.,  Edin.  andLond.,  1912,  XXV, 

319-321. 
'5  Ref.  13,  under  Copper. 
2«  Armit.— Jr.  Hyg.,  1911,  VII  and  VIII. 
"  Layet  (1877),  Homann  (1903),  and  Armit  (1911). 
^*  Armit. — Loc.  cit. 

^^  See  Homann.     Also  Kisskalt,  ref.  14,  above. 

^°  Zadek  (ref.  6,  under  Copper)  mentions  coughing  of  blood  in  certain  instances. 
^'  Ref.  17,  above. 

'2  Vrtjschr.  f.  gerichtl.  Med.,  July  and  Oct.,  1906,  174,  384. 
'^  Weyl's  Handbuch,  footnote,  page  113. 
'^  See  Laureck,  Weyl's  Handbuch,  57. 

Brass 

*  See  New  Inter.  Encyc.  for  list  of  various  products. 
2  Bassett. — Ref.  6,  under  Zinc. 


26  OCCUPATIONAL   INTOXICATIONS 

*  Oliver. — Dangerous  Trades,  1902,  456.     The  mention  of  moisture  excludes  fresh  fumes. 

*  Ref.  3,  under  Zinc. 

*  Pfender,  C.  A. — Jr.  Am.  Med.  Ass.,  Jan.  24,  1914,  296.     Our  recent  investigations  in 

Ohio  have  also  amply  confirmed  Pfender's  observations  upon  "braziers'"  disease. 
6  and  7  Cited  by  Arlidge,  Diseases  of  Occupations,  1892,  447. 

*  John  Hopkins  Hospital  BuU.,  No.  48,  Oct.  9,  1894. 
^  Medicine,  Detroit,  1904,  335. 

"  Jr.  Am.  Med.  Ass.,  1904,  XLIII,  465. 

^^  Medical  Record,  N.  Y.,  Aug.,  1905,  209-217. 

^^  Locii  citis. 

'^  Ref.  3,  under  Zinc. 

"  Zadek. — Ref.  6,  under  Copper.     Also  Roth,  Komp.  der  Gewerbekr.,  1909,  61. 


THE  HEALTH  OF  BRASS  WORKERS 

N  BY  T.  M.  LEGGE.  M.  D.,  London,  England. 

In  the  year  1902  detailed  inquiry  into  the  health  of  brass  workers  in  Bir- 
mingham— the  center  of  the  industry — was  undertaken  by  the  Factory  De- 
partment of  the  Home  Ofl&ce  because  not  only  was  there  ignorance  of  the  real 
prevalence  of  so-called  brassfounder's  ague  among  them,  but  also  because 
the  view  had  been  expressed  that  a  definite  clinical  picture  was  associated  with 
filing,  polishing  or  otherwise  manipulating  brass,  of  which  the  prominent 
symptoms  were  a  green  line  on  the  teeth,  anaemia  and  emaciation. 

In  order  to  obtain  accurate  information  as  to  illness  attributable  to  poi- 
soning by  brass  I  undertook  the  examination  of  233  casters  (among  whom 
were  included  metal  mixers,  casters  proper,  and  casters'  helpers),  and  210 
polishers  and  others  (including  polishers  proper,  dressers,  turners  and  burn- 
ishers). The  object  throughout  was  to  make  comparison  between  those 
exposed  to  fumes  and  those  not  so  exposed.  In  addition  to  the  filling  in  by 
each  one  of  the  men  of  a  printed  form  as  to  the  state  of  his  health  while  work- 
ing in  brass  note  was  made  of  the  height,  v/eight,  chest  measurement  and 
strength  of  grasp  as  tested  by  a  dynamometer;  the  heart,  lungs,  gums  and 
teeth,  were  examined;  and  the  condition  as  to  anaemia,  paresis,  general  health, 
and  prevalence  of  brassfounder's  ague,  was  ascertained.  The  inquiry  was 
carried  out  in  21  factories  in  Birmingham  in  all  of  which,  with  one  exception, 
both  zinc  and  copper  entered  largely  into  the  metal  poured.  Subsequently  I 
visited  the  principal  foundry  in  the  Royal  Arsenal,  Woolwich,  and  examined 
89  persons  of  whom  58  were  engaged  in  casting  gun  metal  into  the  composi- 
tion of  which  zinc  hardly  enters  at  all. 

Tabulation  of  the  results  as  regards  age,  duration  of  employment,  height, 
weight  and  chest  measurement,  showed  differences  so  slight  that  generaliza- 
tion from  them  revealed  nothing  of  importance.  The  strongest  evidence 
perhaps  obtained  in  the  inquiry  that  the  operation  of  casting  is  more  trying 
than  other  brass  work  came  out  from  the  replies  to  the  question.  Do  you 
consider  that  your  health  has  been  in  any  way  injured  by  working  in  brass? 
since  22.7  per  cent,  of  the  casters  as  compared  with  only  11.6  per  cent,  of  the 
polishers  said  they  had  suffered.  Of  193  casters  interrogated  as  to  brass- 
founders'  ague  123  or  63.7  per  cent,  stated  that  they  had  sufl"ered  more  or 
less  frequently  from  the  train  of  symptoms — malaise,  sense  of  weakness, 
shivering  with  chattering  of  the  teeth  and  extreme  feeling  of  cold — character- 
istic of  this  complaint.  There  could  be  no  doubt  as  to  the  extreme  prevalence 
of  the  affection.     The  frequency  of  the  attacks  in  several  cases — often  once 

27 


28  OCCUPATIONAL   INTOXICATIONS 

a  week^ — was  remarkable,  the  attack,  as  has  so  frequently  been  described, 
following  on  return  to  work  after  temporary  absence  for  a  day  or  two. 

There  was  general  censensus  of  opinion  that  the  greater  the  proportion 
of  spelter  in  the  metal  mixture  the  greater  was  the  liabihty  to  attack.  The 
strongest  evidence  I  obtained  on  this  point  was  at  Woolwich  Arsenal.  Among 
the  58  casters  of  gun  metal  where  conditions  of  ventilation  in  the  past  would 
have  led  one,  if  anywhere,  to  expect  heavy  incidence  of  brassfounders'  ague 
six  only  narrated  indefinite  symptoms  suggesting  the  possibility  that  they 
had  suffered.  In  another  foundry  at  the  Arsenal,  however,  where  zinc 
entered  largely  into  the  composition  of  the  metal,  of  the  10  casters  questioned 
all  but  one  gave  a  history  of  frequent  attacks. 

It  was  impossible  not  to  be  struck  by  the  less  satisfactory  appearance  of 
the  casters  as  compared  with  the  polishers.  By  the  sallowness  of  the  com- 
plexion the  occupation  as  a  caster  could  often  be  correctly  guessed. 

Evidence  of  lead  absorption — showing  itself  in  a  blue  line  on  the  gums — 
was  noted  in  four  casters  and  in  16  polishers.  In  one  man  engaged  in  polish- 
ing on  an  emery  wheel  unprovided  with  exhaust  ventilation  paralysis  of  the 
wrists  was  found.  Analyses  of  two  samples  of  brass  dust  made  in  the 
Government  Laboratory  showed  in  the  one  case  2.9  per  cent,  of  lead  and  in 
the  other  2.43.  I  have  no  doubt  that  inhalation  of  brass  dust  containing  so 
small  a  percentage  of  lead  as  these  samples  show  can  in  the  long  run  give  rise 
to  plumbism. 

A  green  line  on  the  teeth  from  formation  of  basic  carbonate  of  copper  was 
noted  in  at  least  65  per  cent,  of  the  polishers  and  16  percent,  of  the  casters. 
It  is,  therefore,  more  an  indication  of  work  involving  exposure  to  dust  rather 
than  to  fumes.     Greenish  coloration  of  the  hair  was  noted  twice. 

The  conclusion  at  which  I  arrived  from  the  inquiry  was  that  work  in  the 
casting  shop  was  more  trying  and  attended  with  greater  injury  to  health  than 
work  in  polishing.  Apart  from  brassfounders'  ague  and  the  occasional  de- 
velopment of  lead  poisoning  among  chandelier  fitters  and  polishers,  I  did  not 
find  symptoms  of  illness  which  suggested  to  my  mind  that  they  could  possibly 
be  due  to  absorption  of  copper  or  brass.  If,  therefore,  so-called  brass  poison* 
ing  were  made  notifiable  in  the  same  way  as  poisoning  by  lead,  arsenic, 
mercury  and  phosphorus,  the  result  would  be  the  reporting  of  any  ill-defined 
sickness  in  persons  showing  a  green  line  upon  the  teeth  or  even  of  persons 
working  merely  in  brass.  Mortality  statistics,  however,  as  for  instance  those 
contained  in  the  Decennial  Supplement  of  the  Registrar  General,  show 
that  there  is  undue  incidence  of  phthisis  among  those  employed  in  brass 
working.  What  was  wanted  in  casting  shops,  I  said,  was  removal  of  the 
fumes  and  in  polishing  shops  removal  of  the  dust.  At  the  time  I  investigated 
the  subject  there  were  not  more  than  three  or  four  out  of  the  900  casting 
shops  in  Birmingham  in  which  attempt  was  made  to  remove  the  fumes 
locally  by  exhaust  ventilation  and  in  the  polishing  shops  only  one. 

Subsequently   in   1907   the  Home  Office  issued   Draft   Regulations  in 


THE    HEALTH    OF   BRASS    WORKERS  29 

accordance  with  the  requirements  of  the  Factory  and  Workshop  Act,  1901, 
which  it  was  proposed  should  apply  to  factories  in  which  the  process  of 
casting  was  carried  on.  Numerous  objections  from  manufacturers  were 
received  (in  consequence  perhaps  of  ambiguous  wording  in  the  Draft)  and  a 
Commissioner  was  appointed  by  the  Secretary  of  State  to  hold  a  public 
inquiry  in  regard  to  the  same  under  section  81  of  the  Act.  At  the  inquiry 
strong  evidence  from  casters  as  to  the  effect  of  the  fumes  on  themselves  was 
heard,  but  perhaps  the  most  striking  evidence  was  that  of  the  Commissioner's 
own  experience  as  stated  in  his  report: 

On  the  occasion  of  one  of  my  visits  to  Birmingham,  after  several  visits  to 
casting  shops  and  seeing  some  pourings,  I  inspected  toward  the  close  of  the 
day  a  strip  casting  shop,  where  the  ventilation  proved  to  be  extremely  bad.  I 
witnessed  four  crucibles  of  brass,  containing  120  lb.  each,  poured  in  succession 
into  strip  moulds,  the  doors  and  windows  being  meanwhile  closed  for  reasons 
hereinafter  referred  to.  The  time  occupied  was  some  15  minutes.  On  com- 
ing out  into  the  air  I  felt  a  sense  of  stifling  oppression  on  the  chest,  which  passed 
away  in  about  an  hour,  a  strong  taste  of  the  fumes,  however,  remaining.  At 
about  10.30  P.M.  the  same  night  symptoms  corresponding  exactlj^  with 
those  of  the  " brassfounders'  ague"  or  "fever"  showed  themselves:  shivering 
and  chattering  of  the  teeth  followed  by  what  appeared  to  be  a  considerable 
degree  of  fever,  which  lasted  for  perhaps  2  hours,  then  a  most  protuse  and 
long-continued  perspiration,  followed  at  last  by  sleep.  In  the  morning, 
however,  I  rose  at  the  usual  hour  with  only  a  slight  headache  and  a  taste  of  the 
fumes  in  my  mouth.  Mr.  Thornton  Lawes,  who  had  been  with  me  through- 
out the  previous  day  on  my  tour  of  inspection,  and  had  witnessed  the  casting 
to  which  I  have  referred,  had  a  similar  attack  of  the  "ague"  or  "fever"  the 
same  night.  On  that  or  the  next  day  I  began  to  feel  pains  in  the  shoulders 
and  chest,  and  for  over  2  months  I  have  suffered  from  these  and  from  asthma- 
tic and  bronchial  symptoms  which  have  been  sufificiently  severe  to  compel  me 
to  give  up  my  work  and  seek  a  cure  in  the  country. 

As  the  outcome  of  this  Inquiry  the  Regulations  which  are  appended  to  this 
article  were  issued  by  the  Secretary  of  State  in  1908  and  now  govern  the 
industry.  In  Birmingham  alone  they  apply  approximately  to  S60  casting 
shops  of  which  about  320  are  exempted  by  reasons  of  the  exception  with 
regard  to  air  space  per  person.  Most  of  the  casting  shops  are  ground  floor 
rooms  with  lean-to  roofs  made  of  slate.  Many  small  and  unsuitable  shops 
have  been  discontinued  during  the  past  few  years.  The  most  popular 
method  by  which  compliance  with  the  Regulations  as  to  exhaust  ventilation 
has  been  secured  is  provision  of  a  large  hood  fixed  about  6  or  7  ft.  above  the 
floor  connected  up  with  a  power-driven  volume  fan.  The  moulds  are  placed 
in  a  leaning  position  against  a  shelf  or  "spilling  hearth"  10  in.  or  more  above 
the  floor  directly  under  the  hood  and,  whilst  pouring,  the  pot  is  rolled  along 
this  shelf  behind  the  moulds.  Another  common  device  in  use — the  most 
successful  form  of  locally  applied  exhaust  ventilation  by  heat  which  I  know — • 
is  that  invented  by  Messers  Rainsford  andLynes,Ltd.,  brass  casters,  of  Bir- 
mingham.    In  this  case,  a  small  cap  is  attached  to  the  crucible  containing 


30  OCCUPATIONAL  INTOXICATIONS 

the  molten  metal  and  connected  by  a  flexible  pipe  some  3  or  4  in.  in  diameter 
to  a  fixed  tube  running  into  the  furnace  chimney.  With  this  apparatus  no 
fan  is  necessary  and  yet,  in  the  act  of  pouring,  at  least  85  per  cent,  of  the 
fumes  never  enter  the  workroom  at  all.  Unfortunately  its  use  is  limited  to 
sand  casting  as  it  is  alleged  that  it  cannot  deal  with  the  enormous  volume 
of  zinc  oxide  fume  given  off  in  strip  or  tube  casting.  The  illustration  shows 
the  mode  of  application.     Progress,  however,  in  regard  to  exhaust  ventilata- 


FiG.   I. — New  method  of  pouring  in  brass  casting;  85  per  cent,  of  the  fumes  are 

taken  away. 

tion  has  been  so  rapid  in  recent  years  that  all  manner  of  devices  now  enable 
occupiers  to  comply  with  the  requirement  as  to  removal  of  the  fumes. 

While  the  exemption  from  the  Regulations  allowed  on  the  ground  of 
ample  cubic  space  per  person  was  necessary,  there  cannot  be  question  that, 
in  comparatively  small  casting  shops,  work  is  carried  on  under  healthier 
conditions  where  there  is  a  fan  to  induce  a  constant  current  of  fresh  air  through 
the  room  while  pouring  is  going  on  than  where,  owing  to  the  exception,  reli- 
ance is  placed  on  natural  means  of  ventilation  only. 

Commencing  in  1902  and  from  that  year  onward  the  inspectors  of  fac- 


THE  HEALTH  OF  BRASS  WORKERS  3 1 

tories  in  Birmingham  and  elsewhere  had  been  pressing,  in  brass-polishing 
shops,  for  action  in  pursuance  of  section  74  of  the  Factory  and  Workshop 
Act,  1 901,  which  states  that  if  polishing  on  a  wheel  is  carried  on  so  that  dust 
is  generated  and  inhaled  by  the  workers  to  an  injurious  extent,  and  it  appears 
to  an  inspector  that  such  inhalation  could  to  a  great  extent  be  prevented 
by  the  use  of  a  fan,  the  inspector  may  direct  that  a  fan  be  provided  within 
a  reasonable  time.  A  spirit  of  emulation  among  the  employers  was  set  up 
and  without  recourse  to  legal  proceedings  having  been  necessary,  it  is  now 
safe  to  say  that  exhaust  ventilation  is  applied  at  all  benches  where  polishing 
is  continuously  done.  Although  from  time  to  time  I  had  when  in  Birmingham 
seen  admirable  instances  of  the  success  of  the  Regulations,  it  was  not  until 
the  beginning  of  the  year  1914  that  I  had  opportunity  of  re\isiting  the  fac- 
tories in  which  I  had  made  my  original  inquiry.  I  then  found  in  every 
casting  shop,  not  exempted  by  reason  of  air  space,  suitable  provision  made, 
in  one  or  other  of  the  ways  described,  for  speedy  removal  of  the  fumes. 
Several  of  the  casting  shops  were  small  and  incidence  of  brassfounders'  ague 
had  been  severe,  but  the  same  men  whom  I  had  examined  under  the  old 
conditions  were  insistent  as  to  the  striking  improvement  in  the  conditions 
of  work  which  had  resulted.  Brassfounders'  ague  in  their  experience  had 
become,  practically  speaking,  a  matter  of  historical  interest  only.  The 
amelioration  in  health,  so  I  was  informed,  w^as  reflected  in  the  lessened 
amount  of  sickness  claims  made  on  their  Society.  The  single  instance  of 
complaint  brought  to  my  notice  was  in  a  large  casting  shop  where  attempt 
had  been  made  to  arrange  a  hood  and  fan  over  spilling  hearths  in  the  center 
of  the  room.  Here  natural  cross  currents  at  times  defeated  the  draught 
induced  by  the  fan  and  explained  the  partial  failure. 

In  conclusion,  I  would  refer  to  the  interesting  experimental  work  pub- 
lished by  Professor  K.  B.  Lehmann  of  Wiirzburg  which  has,  in  my  opinion, 
thrown  much  light  on  the  causation  of  brassfounders'  ague.  By  experiment 
on  the  human  subject  (himself,  his  assistant,  and  a  brass  caster  pecuHarly 
susceptible  to  the  malady  who  volunteered)  he  was  able  to  produce  all  the 
typical  symptoms  of  brassfounders'  ague  by  inhalation  of  the  fumes  of 
burning  zinc  alone  in  a  badly  ventilated  room.  His  conclusions  were  that 
the  malady  could  be  very  easily  produced  in  men  working  with  chemically 
pure  zinc  while  it  is  burning.  The  symptoms  observed  resembled  closely 
the  effects  of  bacterial  infection  through  the  respiratory  system.  Lehmann 
believes  that  some  of  the  cells  lining  the  respiratory  tract  are  destroyed  by 
the  zinc  oxide  fumes  and  it  is  absorption  of  these  dead  cells  which  accounts 
for  the  symptoms.  The  objection  raised  to  the  zinc  theory,  which  at  first 
sight  seems  dif&cult  to  disprove,  is  based  on  the  fact  that  spelter  workers  do 
not  suffer.  The  probable  explanation  of  this  is  that  while  zinc  melts  at  400 
to  5oo°C.,  brass  requires  a  much  higher  temperature  than  this  to  melt. 
When  producing  brass,  the  copper  is  melted  first  at  a  temperature  of  about 
iooo°C.  and  the  zinc  is  added  afterward.     The  higher  the  temperature  the 


32  OCCUPATIONAL   INTOXICATIONS 

more  rapidly  does  the  zinc  bttm  and  the  stronger  are  the  oxide  of  zinc  fumes 
given  off. 

REGULATIONS,  DATED  JUNE  20,  1908,  MADE  BY  THE  SECRETARY  OF  STATE, 
GREAT  BRITAIN,  FOR  THE  CASTING  OF  BRASS 

Whereas  the  casting  of  brass  or  any  alloy  of  copper  with  zinc  has  been  certified  in  pur- 
suance of  Section  79  of  the  Factory  and  Workshop  Act  to  be  dangerous,  I  hereby  in  pur- 
suance of  the  powers  conferred  on  me  by  that  Act  make  the  following  Regulations  and  direct 
that  they  shall  come  into  force  on  the  ist  day  of  January,  19 10,  and  shall  apply  to  all  fac- 
tories in  which  the  casting  of  brass  is  carried  on,  with  the  following  exceptions: 

(i)  The  Regulations  shall  not  apply  to  a  sand-casting  shop  having  an  air-space  equiva- 
lent to  2500  cu.  ft.  for  each  of  the  persons  employed  nor  to  any  other  casting 
shop  having  an  air  space  equivalent  to  3500  cu.  ft.  for  each  of  the  persons 
employed.     Provided — ■ 

(a)  that  provision  is  made  for  the  egress  of  the  fumes  during  casting  by  inlets 
below  and  outlets  above  of  adequate  size,  and 

(b)  that  a  notice  in  the  prescribed  form,  giving  the  prescribed  particulars,  shall 
be  kept  affixed  at  or  near  the  entrance  of  the  casting  shop  and  that  a  copy  thereof 
shall  be  sent  to  the  Inspector  of  the  district,  and 

(c)  that  the  conditions  of  exemption  stated  in  such  notices  are  not  departed 
from. 

(ii)  So  much  of  Regulation  i  as  requires  that  exhaust  draught  shall  be  maintained  dur- 
ing the  process  of  casting  shall  not  apply  in  the  case  of  strip  or  solid  drawn  tube 
casting  or  any  other  class  of  casting  which  the  Secretary  of  State  may  certify  on 
that  behalf,  provided  that — 

(a)  the  exhaust  draught  cannot  be  so  maintained  without  damage  to  the  metal 
(proof  of  which  shall  be  upon  the  occupier) ;  and 

(b)  the  exhaust  draught  is  put  into  operation  immediately  after  the  casting; 
and 

(c)  provision  is  made  for  the  egress  of  fumes  during  casting  by  inlets  below  and 
outlets  above  of  adequate  size. 

(iii)  Where  it  is  proved  to  the  satisfaction  of  the  Chief  Inspector  of  Factories  that  by 
reason  of  exceptional  features  in  the  construction  or  situation  of  a  casting  shop 
or  by  reason  of  the  infrequency  of  the  casting  or  the  small  quantity  or  the  nature 
or  composition  of  the  metal  cast  or  other  circumstances  all  or  any  of  the  Regu- 
lations are  not  necessary  for  the  protection  of  the  persons  employed  he  may  by 
certificate  in  writing  (which  he  may  in  his  discretion  revoke)  exempt  such  casting 
shop  from  all  or  any  of  the  provisions  of  the  same  subject  to  such  conditions  as 
he  may  by  such  certificate  prescribe. 
In  these  Regulations  (including  the  above  provisions  and  exceptions) — 
"Brass"  means  any  alloy  of  copper  and  zinc. 
"Casting"  includes  the  pouring  and  skimming  of  brass. 
"Casting  shop"  means  any  place  in  which  casting  of  brass  is  carried  on. 
"Sand-casting"  means  casting  in  moulds  prepared  by  hand  in  sand  or  loam  or  sand 

and  loam. 
"Sand-casting  shop"' means  a  place  in  which  no  kind  of  casting  other  than  sand- 
casting  is  carried  on. 
"Pot"  includes  any  crucible,  ladle  or  otlicr  vessel  in  which  the  brass  is  skimmed  or 

from  which  it  is  poured. 
"Em|)loyed"  means  employed  in  the  casting  shop  in  any  capacitj'. 


THE    HEALTH    OF   BRASS    WORKERS  33 

"Persons  employed"  means  the  maximum  number  of  persons  at  any  time  employed. 
It  shall  be  the  duty  of  the  occupier  to  observe  Part  I  of  these  Regulations,  and  the  con- 
ditions contained  in  any  certificate  of  exemption. 

It  shall  be  the  duty  of  all  persons  employed  to  observe  Part  II  of  these  Regulations. 

Part  I 
Duties  of  Occupiers 

1.  Casting  of  brass  shall  not  be  carried  on  unless  the  following  conditions  are  complied 
with: 

(a)  There  shall  be  an  efficient  exhaust  draught  operating  by  means  either  of  (i)  a 
tube  attached  to  the  pot,  or  (ii)  a  fixed  or  movable  hood  over  the  point  where 
the  casting  takes  place,  or  (iii)  a  fan  in  the  upper  part  of  the  casting  shop,  or 
(iv)  some  other  effectual  contrivance  for  the  prompt  removal  of  the  fumes 
from  the  casting  shop  and  preventing  their  diffusion  therein.  The  exhaust 
draught  shall  be  applied  as  near  to  the  point  of  origin  of  the  fumes  as  is  reason- 
ably practicable,  having  regard  to  the  requirements  of  the  process,  the  main- 
tenance of  the  exhaust  draught  during  the  process  of  casting,  and  (as  regards 
casting  shops  in  use  prior  to  ist  January,  1908)  the  structure  of  the  premises, 
and  the  cost  of  applying  the  exhaust  draught  in  that  manner. 

(6)  There  shall  be  efficient  arrangements  to  prevent  the  fumes  from  entering  any 
other  room  in  the  factory  in  which  work  is  carried  on. 

(c)  There  shall  be  free  openings  to  the  outside  air  so  placed  as  not  to  interfere  with 
the  efficiency  of  the  exhaust  draught. 

2.  There  shall  be  provided  and  maintained  in  a  cleanly  state  and  in  good  repair,  for  the 
use  of  all  persons  employed,  a  lavatory,  under  cover,  (i)  with  a  sufficient  supply  of  clean 
towels,  renewed  daily,  and  of  soap  and  nail  brushes,  and  (ii)  with  either — 

(a)  A  trough  with  a  smooth,  impervious  surface,  fitted  with  a  waste  pipe  without 
plug,  and  of  such  length  as  to  allow  at  least  2  ft.  for  every  five  such  persons, 
and  having  a  constant  supply  of  warm  water  from  taps  or  jets  above  the 
trough  at  intervals  of  not  more  than  2  ft.;  or 

(6)  At  least  one  lavatory  basin  for  every  five  such  persons,  fitted  with  a  waste  pipe 
and  plug  or  placed  in  a  trough  having  a  waste  pipe,  and  having  either  a  con- 
stant supply  of  hot  and  cold  water,  or  warm  water,  laid  on,  or  (if  a  constant 
supply  of  heated  water  be  not  reasonably  practicable)  a  constant  supply'  of 
cold  water  laid  on  and  a  supply  of  hot  water  always  at  hand  when  required  for 
use  by  persons  employed. 

3.  No  female  shall  be  allowed  to  work,  in  any  process  whatever,  in  any  casting  shop. 

Part  II 
Duties  of  Persons  Employed 

4.  No  person  employed  shall  leave  the  premises  or  partake  of  food  without  carefully 
washing  the  hands. 

5.  No  persons  employed  shall  carry  on  the  pouring  of  brass  without  using  apparatus 
provided  in  pursuance  of  Regulation  i  (a). 

6.  No  person  employed  shall  in  any  way  interfere  without  the  knowledge  and  concur- 
rence of  the  occupier  or  manager  with  the  means  provided  for  the  removal  of  fumes. 

H.  J.  Gladstone, 
Home  Office,  Whitehall,  One  of  His  Majesty's  Principal 

20th  June,  1908.  Secretaries  of  State. 

3 


34  OCCUPATIONAL   INTOXICATIONS 

REFERENCES 

Brassfounders'  Ague,  by  D.  H.  Greenhow.  Medico-Chirurgical  Transactions,  Vol.  XLV, 
1862. 

Brass  workers'  Diseases,  by  D.  Hogben.     Birmingham  Medical  Review,  1887. 

Chronic  Brass  Poisoning,  by  W.  Murray.  British  Medical  Journal,  Vol.  I,  page  1334, 
1900. 

Copper  and  Brass,  by  R.  M.  Simon,  M.  D.,  and  S.  H.  Kuydett.  Article  in  Oliver's  "Dan- 
gerous Trades,"  page  455,  1902. 

Untersuchungen  an  Kupper  Arbeitern,  by  Prof.  L.  Lewin.  Deutsche  Medicinische 
Wochenschrift,  No.  42,  1900. 

Annual  Report  of  the  Chief  Inspector  of  Factories  for  the  year  1905,  pages  388-397. 

Report  on  the  Draft  Regulations  for  the  Casting  of  Brass,  by  W.  Wills.  (Cd.  4154.) 
1908. 

Das  Giess  oder  Zink  fieber,  by  Prof.  K.  B.  Lehmann.  Archiv  fiir  Hygiene,  Vol.  LXXII, 
page  358,  1910. 


SECTION  III 
CARBON  BISULPHIDE  POISONING 

BY  E.  R.  HAYHURST,  M.  D..  Columbus,  Ohio. 

Historical  Notes. — Bisulphide  of  carbon  was  discovered  by  Lampadius, 
the  German  chemist,  in  1796.  Pazen^  seems  to  have  been  the  first  to  call 
attention  to  it  as  an  occupational  poison  (1851)  and  to  have  counselled  cau- 
tion in  its  use.  Duchenne^  (1853)  mentions  its  paralyzing  effects.  Delpech* 
(1856,  1863),  with  description  of  cases,  gave  the  first  comprehensive  picture 
of  its  symptomatology.  Tavera^  (1865)  first  studied  the  blood  changes. 
Since  these  dates  much  experimental  work  and  the  study  of  special  signs  of 
intoxication  have  been  reported  by  various  investigators. 

Chemistry. — Bisulphide  of  carbon  is  a  constituent  of  coal  tar.  It  is  made 
commercially  when  red  hot  carbon,  contained  in  a  retort,  is  treated  with 
sulphur  vapors.  It  is  an  endothermic  compound  and,  therefore,  formed  only 
on  heating.  The  carbon  bisulphide  gas  is  condensed  to  liquid  form,  purified 
and,  when  pure,  is  practically  colorless,  has  a  chloroform-like  odor,  is  very 
limpid,  mobile,  volatile,  refractive,  insoluble  in  water,  but  soluble  in  aU 
proportions  in  alcohol  and  ether  and  to  60  per  cent,  in  oil.  It  dissolves  all 
resins  except  shellac. ^^  It  does  not  dissolve  vulcanized  rubber.  It  dis- 
solves nearly  its  own  weight  of  sulphur  at  38°C.  When  impure  it  has  a 
repulsive  smell  and  a  yellow  color.  Impurities  are  usually  H2S,  sulphur, 
and  sulphydrates  of  carbons.  H2S  cannot  be  demonstrated  in  its  vapors,^" 
at  least  in  suflBcient  quantity  to  produce  poisoning.^^ 

When  passed  through  a  red  hot  tube,  with  chlorine,  it  yields  carbon  tetra- 
chloride (CCI4)  and  sulphur  monochloride  (S2CI2),  two  substances  much  used 
as  rubber  solvents.  Carbon  bisulphide  is  more  inflammable  than  ether  and 
burns  with  a  bluish  flame  yielding  CO2  and  SO2.  In  America  it  is  practically 
all  made  by  the  Taylor  electric-process,  Penyan,  New  York,  and  is  a  rather 
cheap  substance,  averaging  from  8  to  12  cts.  per  pound.  It  has  a  specific 
gravity  of  1.262  and  boils  at  the  low  temperature  of  46.5°C.  Its  vapor  is 
heavy;  density  2.6.  If  evaporated  rapidly,  as  by  passing  a  current  of  air 
through  it,  its  temperature  is  reduced  to  -6o°C.;  hence  it  may  be  employed 
to  produce  low  temperatures. 

Uses. — According  to  Molinari,^^  besides  its  principal  use  of  vulcanizing 
and  dissolving  rubber, 

"Attempts  have  been  made  to  use  it  for  the  extraction  of  sulphur  from 
poor  ores.  It  is  used  for  extracting  aromatic  oils  from  drugs.  It  is  also  used 
in  large  quantities  for  the  extraction  of  oil  from  seeds  and  from  oily  seed 
residues  and  rags.     It  is  also  used  for  degreasing  vegetable  and  animal  resi- 

35 


36  OCCUPATIONAL   INTOXICATIONS 

dues,  such  as  rags,  bones,  meat,  hides,  wool,  etc.  It  is  used  for  preparing 
solutions  of  wax  for  coating  plaster  casts,  and  for  the  preparation  of  waxed 
paper.  It  is  also  used  for  dissolving  out  the  tar  from  many  industrial  products 
[and  in  gas  purification  to  remove  sulphur],-^  for  preparing  various  chemical 
products,  for  making  Greek  fire  (phosphorus  dissolved  in  CS2) ,  for  killing  insect 
pests,  and  more  especially,  in  large  quantities,  for  destroying  phylloxera  in 
vineyards  by  injecting  it  into  the  earth  with  suitable  pumps.  ...  In  1906 
it  was  used  with  good  results  for  destroying  the  nematodes  which  attack 
beet  root." 

It  is  used  in  the  preparation  of  cellulose  for  artificial  silk;  in  cleaning  estab- 
lishments to  remove  grease  spots;  as  a  disinfectant;  and  by  the  Public  Health 
Service  in  destroying  rodents  in  their  natural  haunts.^^ 

In  the  Parke's  process  of  vulcanizing  it  is  used  to  carry  the  sulphur  into 
the  rubber  "in  the  cold."  It  is  practically  never  used  pure,  but  combined  with 
S2CI2,  CChor  with  benzol  (CeHe).  It  renders  rubber  more  elastic, malleable, 
resistant  and  long-lived.  It  is  a  better  solvent  for  rubber  than  benzine  and 
even  better  than  ether,  and  is  likely  to  be  the  principal  solvent  used  in  all 
rubber  and  gutta-percha  cements  which  are  to  dry  quickly. 

It  has  been  advocated  for  the  treatment  of  tuberculosis  (all  forms)  by 
h)qDodermic  injections  and  by  inhalations  of  the  vapor.^" 

Lehmann^"  has  shown  that  i  part  per  million  in  the  air  will  produce  mild 
symptoms,  while  i}-2  parts  will  produce  severe  symptoms.  As  much  as  2 
to  3  parts  per  million  have  been  found  in  work  places. 

Classes  of  Workers  Most  Liable  to  Poisoning.— (i)  Rubber  workers; 
(2)  oil  and  grease  extractors;  (3)  those  using  cements  dissolved  in  CS2;  and 
(4),  rarely,  those  concerned  with  its  manufacture  and  various  other  uses 
mentioned. 

Predisposing  Factors  in  Industry. — Among  these  are  hot  weather  or 
overheated  rooms,  also  working  in  low  places  and  close  to  the  floor.  Poison- 
ing occurs  through  breathing  the  vapors,  or  getting  the  fluid  on  the  skin, 
or  having  it  splashed  upon  the  clothing.  Good  ventilation  in  recent  times 
has  greatly  decreased  cases  and  usually  only  milder  symptoms  show.^^ 
In  Belgium,  Galet^^  says  it  causes  "le  plus  grand"  per  cent,  of  injuries  and 
incapacities  for  work.  Repairers  of  belts  in  factories  who  use  cement  dis- 
solved in  CS2  are  affected,  Briau^^  finding  as  many  as  8  of  30  to  be  mentally 
"off."  It  is  the  cause  of  "folic  du  cuir"  or  leather-workers'  insanity.  It  is 
used  by  shoemakers  in  applying  invisible  patches.  Shoemakers  may  be  very 
easily  poisoned  because  of  their  close  quarters,  sitting  near  the  floor,  lack  of 
precautions  and  ignorance  of  the  poisonous  character  of  the  gutta-percha 
solvent  used.  The  most  susceptible  persons  are  the  ill-nourished,  neurotic, 
alcoholic,  female  and  young  persons. 

In  Ohio  where  over  30,000  workers  were  found  to  be  employed  in  the 
rubber  industry  (1914),  less  than  i  per  cent,  came  into  contact  with  CS2. 
The  classes  usually  exposed  were:  (i)  Rubber  cement  makers  (exposure 
usually  quite  limited  since  the  mixing  is  mechanically  done  in  closed  up 


CARBON  BISULPHIDE    POISONING 


37 


containers).  (2)  Cement  tube-  and  can-fillers  (more  exposure,  but  it  was 
found  that  boys  and  men  so  engaged  were  a  rapidly  changing  lot  or  rotated 
with  other  work.     Mild  symptoms  were  a  frequent  complaint,  however). 

(3)  "Cold  curing"  of  drug  sundries  (gloves,  caps,  nipples,  bags,  cots,  etc.), 
and  splicing  ends  of  inner  tubes  for  tires  (exposures  varied  in  plants,  but 
some  form  of  local  exhaust  ventilations  was  usually  present,  or  a  more  or 
less  complete  confinement  of  the  odors  within  cupboards,  or,  finally  CCI4 
was  largely  substituted  for  CS2.     Some  moderately  severe  cases  were  found). 

(4)  Transmission  belt  makers.  Balata  is  the  kind  of  rubber  usually  em- 
ployed (exposure  varied  but  quarters  were  spacious  and  not  many  employees 
thus  engaged.  Reports  of  acute  cases  in  the  past  were  all  that  could  be 
found).  (5)  Water-proofing  and  spreading  of  rubber  onto  fabrics  (CS2 
used  very  limitedly,  if  at  all,  for  this  purpose,  since  benzine  seems  to  be  the 
universal  solvent).     In  almost  no  processes  were  females  exposed  to  CS2. 

Pharmacology  and  Animal  Experiments. — Oliver^^  found  that  CS2 
was  a  very  deadly  poison  to  animals,  and  a  more  powerful  anagsthetic  than 
chloroform  and  more  lasting  in  its  effects.  A  rabbit  which  inhaled  the  vapor 
for  a  short  time  showed  intense  excitement,  intoxication,  impulsion,  followed 
by  a  deep  sleep,  and  on  regaining  consciousness  its  hind  limbs  were  paralyzed 
and  so  remained  for  i  hour.  Animals  exposed  more  slowly  died  within  3 
to  21  days,  during  which  time  they  lost  flesh,  showed  tremors,  were  easily 
fatigued,  became  paralyzed  in  the  hind  limbs  and  died  convulsed.  The 
urine  was  excessive,  no  albumin  was  present,  there  was  but  little  urea, 
although  considerable  sugar  at  death. 

The  cells  of  the  motor  areas  of  the  cortex  showed,  by  Golgi's  method, 
cytoplasm  stained  unequally  and  axis-cylinders  distorted.  Oliver  states 
that  it  is  a  fairly  safe  anassthetic,  but  the  odor  is  too  repulsive  for  use  and  it 
produces  too  much  muscular  jactation.  Red  cells  are  not  disintegrated 
(dog  and  rabbit);  spectroscopic  findings  are  all  negative. 

There  occur  extravasations  in  the  lungs  (Poincare^)  and  stomach  walls ;^* 
pneumonia, ^^  degeneration  of  liver  cells,  of  splenic  pulp,  and  sometimes 
nephritis,  and  gastro-enteritis.  The  myelin  substance  of  the  nervous 
system  is  broken  up  into  fatty  droplets,^  and  emboli  occur  in  the  blood- 
vessels of  the  brain.  The  blood  findings  in  animals  have  been  well  investi- 
gated and  do  not  differ  materially  from  those  in  man  (see  under  Pathology). 

Pathology. — Persons  poisoned  by  bisulphide  of  carbon,  in  the  course  of 
conducting  occupational  processes,  usually  show  atrophy  and  fatty  degenera- 
tion of  muscular  and  connective  tissues  with  loss  of  normal  fat.  There 
may  be  dryness  and  contraction  of  the  skin  due  to  the  fatty  solvent  action 
of  CS2  (Perrin).^^  The  urine  in  acute  cases  may  give  a  dark-brownish  color 
(Galet)  with  Fehhng's  solution,  due  to  the  presence  of  hematin  from  destroyed 
red  cells.  Hydrobilirubin  and  indican,  as  well  as  albumin  and  casts  occur 
in  older  cases.  Its  essential  action  on  the  blood  is  hemolysis.  Cenci^** 
carefully  studied  12  afflicted  workers  who  had  been  exposed  for  long  periods, 


38  OCCUPATIONAL   INTOXICATIONS 

while  engaged  in  the  extraction  of  oil  from  olives,  and  obtained  blood  findings 
as  follows:  (i)  chloranjemia,  (2)  hypoglobulia;  (3)  white  cells  not  affected, 
(4)  alkalinity  of  the  blood  reduced  in  all  cases,  (5)  red  corpuscle  resistance 
greatly  increased,  (6)  no  apparent  effect  upon  coagulation  time.  All  of 
these  conditions  returned  to  normal  after  withdrawal  from  the  work  and 
within  a  period  of  a  few  weeks  or  months.  Jump  and  Cruice^"*  report  hemo- 
globin 40  per  cent,  with  red  and  white  cell  count  normal.  Galet^^  found  no 
granulations  in  the  cells  in  either  acute  or  chronic  cases  in  six  men.  Laboul- 
bene^  was  the  first  to  cite  cases  showing  cutaneous  "taches  ecchymotiques," 
later  followed  by  pigmentation.  These  appeared  upon  the  limbs  and  thorax. 
Vesicles  may  appear. 

Symptomatology. — Two  types  of  industrial  cases  are  recognized,  acute 
and  chronic,  the  latter  with  two  stages,  excitement  and  depression.  Acute 
industrial  poisoning  is  rare  to-day.  Extensive  users  of  the  substance  appear 
to  be  well  informed  of  its  dangers.  However,  in  Ohio  in  the  first  6  months  of 
the  year  1914,  two  instances  came  to  our  notice,  which  may  have  been  due  to 
carbon  bisulphide,  in  one  of  which  sudden  paralytic  attacks  occurred  on 
each  of  two  times  the  patient  returned  to  work,  while,  in  the  other,  puzzling 
symptoms,  which  lasted  a  few  days,  were  followed  by  death  with  hemorrhages 
from  the  various  orifices.  In  rubber  workers  symptoms  of  carbon  bisulphide 
poisoning  are  apt  to  be  accompanied  by  those  due  to  benzine,  benzol,  sul- 
phur monochloride  and  carbon  tetrachloride,  which  are  usually  employed, 
one  or  all,  with  the  bisulphide. 

The  acute  cases  have  as  chief  symptoms:  (i)  circulatory  disturbances, 
pallor,  headaches,  throbbing  of  temples,  pains  in  nape  of  neck  and  crown  ra- 
diating to  temples  and  frontal  region,  palpitation,  fainting;  (2)  drowsiness;  (3) 
digestive  disturbances,  especially  nausea,  anorexia,  repeated  vomiting,  per- 
haps diarrhea,  but  sometimes  colic  and  constipation;  (4)  nervous  manifesta- 
tions, especially  incoordination,  weakness  in  legs,  signs  of  great  fatigue, 
unsteady  gait,  impulsive  acts,  as  throwing  one's  self  under  vehicles,  into 
machinery,  out  of  windows,  etc. — mania  with  homicidal  and  suicidal  re- 
sults are  known.  There  are  also  marked  hallucinations  of  sight,  hearing, 
taste  and  smell.  Death  may  follow  during  a  convulsion  or  during  coma. 
The  breath  has  the  fetid  odor  of  sulphides. 

Chronic  symptoms  are  the  usual  ones  and  the  onset  may  appear  within  a 
few  weeks  or  months,  or  only  after  years  in  the  work.-^  The  stage  of  ex- 
citement comes  first,  and  is  usually  evinced  while  at  work  as  exhilaration, 
loquaciousness  and  undue  jollity.  Following  this  comes  faintness,  giddiness, 
drowsiness,  exhaustion  and  headache.  At  home  the  patient  is  irritable,  de- 
pressed, tastes  the  bisulphide  in  everything,  sleeps  in  daytime,  cannot  sleep 
at  night,  and  has  bad  dreams.  Return  to  work  temporarily  invigorates 
again.  Cases  investigated  in  Ohio  complained  of  feeling  "drunk,"  when 
fellow-workers  would  take  them  into  the  open  air  (with  little  concern). 
Usually  new  men  were  the  ones  most  afflicted.     Hysterical  manifestations^ 


CARBON   BISULPHIDE    POISOXIXG  39 

are  particularly  common,  and  more  so  in  females.  There  are  all  manner  of 
psychical  phenomena, from  "crazy,"  excited  talk,  to  ravings  and  acute  mania. 
Workers  complain  of  dysthesias,  which  assume  geometrical  distributions; 
numbness  and  tingling;  anaesthesia  of  parts;  "that  contact  of  the  hand  with 
the  body  seems  that  of  some  other  person's; "^^  cramp-like  pains;  spasms  of 
face  muscles;  and  trembling.  There  is  a  drunken  gait,  exaggerated  reflexes, 
and  a  Romberg  sign  is  usually  present.  A  violent  explosive  temper  with 
symptoms  resemxbling  delirium  tremens^^  may  prove  puzzling  in  diagnosis. 
Peripheral  neuritis,  mostly  motor  in  type,  is  easily  demonstrable.  Digestive 
disturbances  include  vomiting,  especially  in  females,  loss  of  taste,  subjective 
rotton  odors,  and  diarrhea,  which  may  alternate  with  constipation.  Delpech^ 
cites  an  instance  where  a  capricious  appetite  showed  that  "he  spent  lo  francs 
to  each  6  sous'  worth."  The  pulse  is  rapid  and  there  may  be  abundant  nose 
bleed -at  times.  Menorrhagia  and  miscarriages  occur,  while  a  violent  sexual 
passion  possesses  males. -^  Hearing  is  early  impaired,  and  more  often  than 
sight.  Disturbances  of  sight^^  come  later  on — dimness  of  vision,  blind  spots, 
disturbances  of  color  fields — and  appear  to  be  a  retrobulbar  neuritis  with 
changes,  later,  in  the  retina  and  choroid.  ^^ 

In  the  stage  of  depression,  which  follows  the  above  in  the  course  of  a  few 
weeks,  there  is  noticeable  nutritive  disturbances,  atrophy  and  emaciation,  or 
sometimes  just  softness  of  the  muscles  and  tissues,  with  fibrillations  and  re- 
laxation. Pallor  and  weakness  may  develop  into  actual  cachexia.  Func- 
tional troubles  are  very  common,  and  include  paraesthesias  (itching,  formica- 
tions), great  depression,  weakness  of  memory  for  words,  puerile  enunciation, 
melancholia,  hypochondria  and  torpor.  Organic  nervous  symptoms  are 
almost  equally  common,  and  consist  of  partial  and  complete  paralyses,  espe- 
cially of  extensor  groups  of  muscles  (arms,  hands,  feet),  leading  to  wrist 
drop,  steppage  gait,  and,  later,  contractures.  The  fingers  which  come  into 
contact  with  carbon  bisulphide  are  apt  to  become  extended,  stiff  and  numb.^ 
There  is  often  tremor  of  the  extended  hands  and  tongue,  exaggerated  on  use. 
The  lips  tremble,  and  quite  violently  so,  when  attempting  to  whistle.^* 
Absent  knee-jerks  and  other  deep  reflexes,  with  loss  of  sensations  caused 
Berbes  (1885)  to  speak  of  the  condition  as  pseudo-tabes.^®  There  is  constipa- 
tion all  the  time.  Skin  pigmentation  may  be  present.  The  patient  cannot 
read  because  of  dim  vision;  fingers  may,  with  difficulty  be  counted.^-  Pupils 
appear  normal,  there  is  no  diplopia;  the  examination  of  the  fundus  shows, 
at  first,  a  congested  disc  with  hyperaemia  of  retinal  vessels,  and,  later,  pallor, 
said  to  be  more  marked  in  the  temporal  half.  Deafness  may  be  marked. 
Sexual  power  is  entirely  lost;  atrophy  of  testes  may  be  plainly  discernable. 
Sterility  obtains  in  females.  Ten  cases  (all  males)  discovered  among  the 
rubber  workers  in  Ohio,  lay  between  the  excitable  stage  and  this  chronic  de- 
pressive type,  with  some  symptoms  especially  well-marked. 

Diagnosis. — Carbon  bisulphide  gives  no  characteristic  sign  or  syndrome. 
Peripheral  neuritis,  hysterical  symptoms,  and  history  of  exposure  usually 


40  OCCUPATIONAL   INTOXICATIONS 

suffice  for  diagnosis.  Physicians  in  rubber  districts  are  so  confused  with  the 
multiplicity  of  poisons  used  in  that  industry  that  they  usually  style  all 
patients  "rubber  poisoned."  An  attempt  is  here  made  to  distinguish  be- 
tween them.  Acute  cases  are  to  be  distinguished  from  poisoning  due  to: 
(a)  Anilin — sudden  weakness  of  legs,  sudden  swooning,  cyanosis  of  lips,  pale 
or  suffused  face,  air-hunger,  strangury,  bloody  urine,  methemoglobin,  stupor, 
apt  to  continue  for  24  hours  or  longer,  and,  if  death  does  not  occur,  bladder 
irritation  and  skin  eruptions  may  follow,  (b)  Benzine  — usually  begins  with 
fooHsh  prattle,  laughter,  shouting,  trembling  and  jerking — "the  benzine 
jag" — collapse,  pallor  changing  to  cyanosis,  syncope,  all  with  quick  recovery 
in  fresh  air.  (c)  Benzol — is  more  of  an  irritant,  shows  slight  flushing  of  face, 
followed  by  pallor,  watery  eyes,  nasal  discharge,  coughing.  When  uncon- 
scious, lips  are  of  scarlet  hue,  blood  is  bright  red  and  thin,  tonic  and  clonic 
spasms  are  present;  symtpons  are  much  worse  and  more  prolonged  than  those 
due  to  benzine,  (d)  Sulphur  monochloride — harmful  only  when  it  is  broken 
up  by  moisture  (steam)  into  SO2  and  HCl  vapor,  (e)  Carbon  tetrachloride 
— rarely  poisonous  industrially,  but  will  produce  symptoms  similar  to  chloro- 
form, with  nausea,  coughing,  headache  and  pronounced  excitement.  Around 
tar  and  gas  works:  (/)  Hydrogen  sulphide— an  irritant,  producing  watery 
eyes,  running  nose,  coughing,  herpes  on  lips,  contracted  pupils,  slow  pulse, 
Cheynes-Stokes  respiration,  tonic  spasms,  delirium  and  coma;  breath  smells 
of  sulphides,  also,  (g)  Carbon  monoxide  and  illuminating  gas  poisoning — 
may,  rarely,  be  confused  with  carbon  bisulphide  poisoning.  Finally,  (h) 
Acute  alcoholism — the  patient  is  rather  less  impulsive,  and  there  is  a  different 
odor  to  breath;  unconsciousness  is  not  coma. 

Chronic  poisoning  shows  itself  principally  in  the  history  of  the  case. 
A  period  of  several  days  or  weeks  of  drunken  jollity  and  excitement,  followed 
by  depression,  with  paralytic,  digestive  and  nutritive  disturbances,  is 
quite  characteristic.  The  condition  is  to  be  differentiated  from:  (a)  Lead 
poisoning,  which  is  more  common  in  rubber-tire  and  hard-rubber  factories 
than  bisulphide  poisoning.  Here  the  predominance  of  colic,  constipation, 
vomiting,  with  peculiar  pallor  and  blue  line  on  gums,  and  lead  in  urine  are 
diagnostic,  (b)  Mercurialism — trembling,  salivation,  gingivitis,  diarrhea, 
and  foul  breath  are  characteristic,  (c)  Duchenne^  declared  that  time  only 
would  separate  bisulphide  poisoning  from  paresis,  since  death  is  not  frequent 
in  the  former.  This  condition  and  (J)  locomotor  ataxia,  however,  have 
characteristic  pupil,  reflex  bladder  and  rectal  disturbances  and  specific 
blood  and  spinal  fluid  tests,  {e)  Progressive  muscular  atrophy  presents  no 
digestive  disturbances,  while  mental  faculties  remain  good.  (/)  Hysteria 
probably  cannot  be  differentiated  symptomatically,  but  note  especially 
signs  of  peripheral  neuritis  of  toxic  origin,  (g)  Many  mild  cases  probably 
pass  as  neurasthenia.  (/?)  Chronic  alcoholism  with  neuritis  exhibits  cutane- 
ous and  muscular  tenderness,  features  usually  absent  in  CSo  poisoning. 
Also  eye  symptoms  are  not  prominent.     (/)  The  dulled  mentality,  muscular 


CARBON  BISULPHIDE    POISONING  4I 

weakness  and  slow  movements,  which  accompany  or  follow  chronic  gas 
poisoning  must  be  thought  of. 

Prognosis. — Of  the  eight  cases  studied  by  Briau,^^  two  had  mental 
alienation,  one  had  presenile  involuntaries,  one  was  profoundly  stupid, 
three  suffered  paresis  of  legs,  with  pains  in  limbs,  and  one,  brutal  genital 
excitation.  Except  the  first  three,  all  recovered,  with  the  possible  exception 
of  full  capacity  for  work.  Delpech^  says,  "He  who  has  worked  in  sulphur 
is  never  again  a  man."  Usually  cases  lightly  affected,  or  only  acutely  affected, 
and  who  get  out  of  the  work,  are  not  harmed.  Chronic  poisoning  rarely 
results  in  death,  except  through  cachexia.  Eye  symptoms  usually  recover, 
hearing  recovers  more  slowly,  while  memory  for  words  seems  to  be  one  of 
the  last  functions  to  be  reestablished. 

Peterson*  reports  recovery  in  three  cases  of  mania  within  9  to  17  months. 
Bard^  reports  cases  of  homicide  and  suicide,  and  another  case  which 
recovered  from  mania. 

Treatment.— Prophylaxis  is  usually  easy.  Workers  should  stand  on 
raised  platforms,  not  down  in  pits  or  low  places.  They  should  be  selected, 
instructed,  alternated  and  allowed  only  short  applications  at  this  work. 
They  should  wear  impervious  clothing,  rubber  gloves,  and  boots.  Local 
exhaust  systems;  slatted  floors  with  powerful  exhausts  beneath;  fresh  air 
from  windows  stirred  up  by  electric  fans;  the  process  confined  within  special 
cupboards  with  apparatus  for  subsequently  drying  the  goods,  all  handled 
mechanically — -these  are  some  of  the  various  means  employed  to  prevent 
poisoning.  It  should  be  remembered  that  clothes,  hands,  walls,  floors,  etc., 
become  impregnated  with  CS2  and  that  all  need  thorough  and  frequent 
cleaning.  Especially  should  the  hands  and  fingers  be  kept  out  of  CS2 
solutions. 

Carbon  tetrachloride  is  the  natural  substitute,  having  many  advantages, 
but  is  more  expensive.  Yet  it  is  extensively  used  in  Ohio.  Some  patent 
harmless  substitutes  are  also  on  the  market.^-  Substitution  of  other  curing 
processes  (steam,  vapor  cures  with  sulphur  monochloride  alone,  sulphur 
chloride  with  carbon  tetrachloride,  etc.)  have  largely  replaced  the  old 
"acid"  or  "cold"  cure  in  rubber  districts. 

In  cases  of  acute  poisoning,  remove  to  fresh  air,  give  warm  bath  or  cold 
affusions,  accordingly,  as  excitement  or  stupor  prevail.  The  pulmotor  may 
be  necessary.  For  subacute  or  chronic  symptoms  the  patient  should  quit 
the  work  at  once.  He  should  be  given  nitrogenous  food  to  prevent  muscular 
atrophy,  with  such  drugs  as  strychnine,  quinine,  phosphorus,  iron,  iodides 
and  arsenic.  For  the  muscular  conditions,  electricity  (galvanism),  vapor 
baths  and  massage  are  indicated. 

REFERENCES 

^  Pazen. — Chemie  industrelle,  1851. 

2  Duchenne  de  Boulogne. — Memoires  sur  la  paralysie  generale.     Arch.  gen.  de  Med.,  1853. 


42  OCCUPATIONAL   INTOXICATIONS 

^  Delpech. — 2e  Memoire.     Acad,  de  Sc,  1861,  publie  in  Ann.  d'Hyg.  et  de  Med.  16g., 

1863,  IX,  65. 
^  Tavera. — These  Paris,   1865. 
^  Poincare. — Arch,  de  phys.,  1875. 
^Laboulbene. — Soc.  Med.  d.  Hop.,  1876. 

'  Marie,  Pierre.— Bull,  de  Soc.  Med.  de  Hop.  de  Paris,  1888,  V. 
^  Peterson.— Boston  M.  &  S.  J.,  1892,  XXVII. 
^  Bard.— Cal.  Pract.,  1892,  VII. 

10  Lehmann,  K.  B.— Arch.  f.  Hyg.,  1897,  XX,  894,  26. 

11  Friedenwahl,  H.— The  Newer  Pathology  of  the  Retina.     Jr.  Am.  M.  A.,  1901,  XXXVII, 

1443- 
1-  Heath,  F.  C. — Amblyopia  from  Carbon  Bisulphide  Poisoning.     Ann.  of  Ophth.,   St. 

Louis,  Jan.,  1902. 
1'  Hauft,  Hans  George. — Beitrage  zur  Kenntnis  der  Schwefelkohlenstoffvergiftung.     Arch. 

intern,  de  Phar.  et  de  Ther.,  1903,  II,  155-200. 
"  Jump,  H.  D.,  and  Cruice,  J,  M. — Chronic  Poisoning  from  Bisulphide  of  Carbon.     Univ. 

of  Penn.  Med.  Bull.,  July-Aug.,  1904,  193-196. 
15  Coronulas  (Athens,  Or.).- Chicago  Med.  Soc,  Jr.  Am.  M.  A.,  1904,  XLIII,  1657. 
1''  Pigeon,  L.— Du  sulfo-carbonisme  professionel.     Paris  Thesis,  March  23,  1905. 
"  Aitoff,  Vladimir. — Effects  du  sulfure  de  carbone.     Paris  Thesis,  1905. 
1*  Galet,  O. — Empoisonnement  par  le  sulfure  de  carbone  et  sulfocarbonisme  professionnel. 

La  Clinique  (4  illustrations),  Brus.,  1906,  501. 
1^  Off  ret,  Alfred. — Essai  sur  Famblyopie  par  le  sulfure  de  carbone.     Paris,  1906,  62  p, 

I  pi.,  8°. 
2°  Cenci,  Francesco. — SuU  'anemia  da  sulfuro  di  carbonio.     Ann.  d'ig.  sper.,  Roma,  1907, 

17. 
21  Oliver,  Sir  Thos. — Allbutt  and  RoUeston's  System,  1909,  II,  pt.  I,  102 1. 
2- Pearson,  H.  C- — Crude  Rubber  and  Combining  Ingredients,  2nd  Ed.,   1909,  227.     Also 

"Rubber,"   Philip   Schridrowitz,  Methuen  &  Co.,  London;  and  Heil  and  Esch: 

"The  Manufacture  of  Rubber  Goods,"  Chas.  Griffin  &  Co. 
2^  Rucker,  Wm.  C. — Rodent  Extermination  in  "The  Rat  and  Its  Relation  to  the  Public 

Health."     Special  Bull.  U.  S.  P.  H.  &  M.  H.  Ser.,  1910,  158.     Also  McClintic,  Thos. 

B.,  Killing  of  Wild  Mammals.     P.  H.  Reports,  191 2,  XXVII,  pt.  I,  736. 
2*  Sommerfeld  &  Fischer.^List  of  Industrial  Poisons.     U.  S.  Labor  Bull.  No.  100,  191 2. 
-5  Briau   (de  Creusot).- — Hygiene  Industrielle.     Y-a-til  une  "Folic  du  cuir"?     Empois- 

sonement  chronique  par  le  sulfure  de  carbone.     Lyon  Med.,  191 2,  119,  897-901. 
^'^  Molinari,  Ettore.- — General  and  Industrial  Chemistry.     Trans,  by  E.  Feilmann,  1912,  I, 

395,  P.  Blakiston's  Son  &  Co. 
2'  Rambousek,  J. — Industrial  Poisoning.     Trans,  by  T.  M.  Legge,  1913,  Edward  Arnold, 

Lond. 
^*  Luig,  Bruno. — Beitrage  zur  Schwefelkohlenstoffvergiftung  und  Benzol  in  Akuten  und 

Chronischen  Versuchen.     Wiirzburg,  1913,  E.  Monnich,  53  p.,  8°. 


SECTION  IV 
CARBON  MONOXIDE  POISONING 

BY  G.  L.  APFELBACH.  M.  D.,  Chicago,  111. 

The  subject  of  carbon  monoxide  poisoning  is  an  intricate  one.  It  is  not 
difficult  to  find  that  workers  in  certain  industries  are  being ''gassed,"  either  by 
appreciable  quantities  or  by  small  continuous  doses  of  this  gas.  It  is, 
however,  difficult  to  determine  the  sequelae  or  subsequent  effects  of  carbon 
monoxide  gassing.  Many  factors  make  a  scientific  conclusion  of  the  effects 
of  carbon  monoxide  gas  prohibitive.  These  are  sx-philis,  alcoholism,  poor 
nourishment,  insanitary  home  conditions  and  surroundings,  and  the  element 
of  fatigue  and  high  temperatures.  These  factors  had  to  be  considered  in  the 
investigation  of  1910  by  the  Illinois  Commission  on  Industrial  Diseases,  and 
are  likewise  reflected  in  this  chapter. 

Acute  carbon  monoxide  poisoning  is  that  condition  in  which  the  person 
affected  has  been  subjected  to  such  a  toxic  dose  of  the  gas  as  to  produce  either 
coma  or  such  a  train  of  subjective  and  objective  findings  as  to  be  readily 
attributed  to  "gassing."  Chronic  carbon  monoxide  poisoning  results  in  the 
worker's  being  subjected  to  repeated  or  continuous  small  doses  of  carbon 
monoxide  gas,  not,  however,  producing  at  any  one  time  a  marked  symp- 
tom-complex. 

Before  going  into  the  industrial  medical  importance  of  this  toxic  agent, 
we  must  pause  to  consider  with  what  temerity  we  use  this  most  poisonous 
gas  in  our  everyday  life.  During  childhood  the  writer  became  acquainted 
with  the  subject  of  carbon  monoxide  poisoning  when  the  kindly  grandmother 
warned  her  grandchildren  to  keep  the  stove  door  closed,  especially  at  such 
times  during  which  the  blue  flames  skipped  about,  between  and  on  the  surface 
of  the  burning  coals.  We  permit  our  houses,  even  our  sleeping  rooms,  to 
be  surrounded  by  a  network  of  pipes  containing  this  deadly  gas,  making  us 
the  victims  of  accidental  leakages.  Our  illuminating  gases  vary  in  carbon 
monoxide  content,  the  toxic  agent  of  the  gas.  Carburetted  water  gas  is 
used  extensively  throughout  the  United  States  for  illuminating  purposes 
with  contents  of  about  30  per  cent,  carbon  monoxide.  Since  0.5  per  cent, 
to  i.o  per  cent,  of  carbon  monoxide  or  1.5  per  cent,  to  3.0  per  cent,  of  illu- 
minating water  gas  is  rapidly  fatal,  accidental  leakage  of  this  gas  in  our  bed- 
rooms often  causes  death.  Accidental  "gassing"  was  more  common  during 
the  introductory  period  of  illuminating  gas  than  at  present.  Many  cases 
have  also  occurred  from  neglect  of  closing  stove  doors,  from  back  draught 
of  hearths  or  fireplaces,  from  old-style  bake  ovens  and  charcoal  braziers. 
The  use  of  any  form  of  fuel,  such  as  charcoal,  wood,  coal,  kerosene  and  gas,  is 

43 


44  OCCUPATIONAL    INTOXICATIONS 

dangerous  in  any  room  without  an  adequate  method  of  drawing  ofif  the  prod- 
ucts of  combustion.  A  case  in  point  was  recently  reported  to  the  writer. 
A  young  man  was  overcome  by  carbon  monoxide  while  taking  his  bath, 
the  room  being  heated  by  a  portable  gas  stove  in  which  the  carbon  monoxide 
formed  at  the  cooling  surfaces  of  the  stove. 

Police  records  of  almost  every  city  show  numerous  cases  of  gas  poisoning, 
often  proving  fatal,  attributed  to  intentional  suicide.  The  Paris  records, 
for  the  9  years  from  1834  to  1843,  show  a  total  of  4595  deaths  due  to  suicide, 
of  which  1432  were  accomplished  by  means  of  carbon  monoxide.  The 
charcoal  brazier  became  the  popular  means  of  suicide  in  France,  so  much  so 
that  we  find  frequent  reference  to  it  even  by  writers  of  fiction  such  as  Dumas, 
Victor  Hugo  and  Eugene  Sue.  With  each  decade  this  practice  increased, 
until  the  records  of  1891  in  Paris  disclose  the  surprisingly  large  number  of 
848  suicides  by  this  method. 

Additional  accidental  poisonings  from  carbon  monoxide  gas,  other  than 
industrial,  have  occurred  in  many  different  ways,  chiefly  from  fires  made  with 
briquettes,  used  in  heating  cabs;  from  chemical  laboratories;  among  persons 
living  in  the  neighborhood  of  gas-producing  industries;  from  gasoline  auto- 
mobiles and  launches.  Reference  is  made  to  the  numerous  stories  about 
tramps  expiring  in  the  warmth  of  a  brick  or  lime  kiln.  This  gas  is  often 
formed  by  smouldering  timbers  after  large  conflagrations  in  factories, 
theatres,  and  other  buildings.  The  writer  remembers  reading  about 
chemical  analyses  of  air  upon  the  discharge  of  German  field  artillery  using 
smokeless  powder.  The  examination  of  this  air  disclosed  the  fact  that  30 
per  cent.  CO  was  present.  Surgeon  General  Stokes,  U.  S.  N.  finds  that  the 
pulse  rate  of  men  rises  rapidly  from  72  to  120  within  10  minutes  after  firing 
guns  in  the  turrets  on  battleships.  He  also  observes  that  the  so-called 
"heat  prostrations"  in  the  stoke  rooms  are  often  due  to  carbon  monoxide 
and  other  gases. 

CHEMISTRY 

Carbon  monoxide  is  seldom  found  in  a  free  state,  except  in  the  chemical 
laboratory  and  in  old  gas  mains  where  it  hes  inert  in  brick,  flue  dirt,  soot,  oil, 
and  pools  of  water.  The  gas  is  colorless,  tasteless,  and  without  odor,  although 
some  writers  claim  its  odor  to  resemble  that  of  garlic.  It  burns  with  a 
blue  flame,  but  does  not  support  combustion.  It  has  a  specific  gravity  of 
0.967.  One  liter  weighs  1.25  grains.  It  is  very  diffusible  and  readily  held 
inert  by  dust  and  oils.  Claim  has  been  made  that  it  is  able  to  diffuse 
through  red  hot  iron;  however,  such  proof  is  lacking  in  our  experience. 
It  is  readily  taken  up  by  CuCl. 

CusClsplus  2CO  =  Cu3Cl2.3CO.4H3O 

This  reaction  is  commonly  used  in  gas  analysis  for  removing  the  volume  of 
carbon  monoxide. 


CARBON    MONOXIDE    POISONING  45 

A  good  qualitative  and  quantitative  method  for  detecting  and  measuring 
the  carbon  monoxide  content  of  a  gas  is  to  pass  the  gas  through  KOH  which 
removes  CO2  and  then  through  I2O5,  which  liberates  iodine.  The  iodine  is 
recovered  in  a  starch  solution,  allowing  the  determination  of  CO.  The 
following  reaction  occurs: 

I2O5  plus  5Co^5C02  plus  I2 

Carbon  monoxide  gas  is  most  frequently  the  result  of  incomplete  com- 
bustion of  carbonaceous  materials.  Wherever  combustion  of  carbon-con- 
taining material  occurs,  we  find_Q£)  as  a  by-product.  Complete  combustion 
is  the  rarer  occurrence,  as  observed  in  our  furnaces  and  stoves.  The  amount 
of  CO  formed,  however,  may  not  be  perceptibly  noticeable.  Even  the 
smoking  of  a  cigar  or  cigarette  is  accompanied  by  the  formation  of  JCO  gas. 
Combustion  depends  on  the  presence  of  oxygen,  in  a  practical  way  on  the 
draft  or  on  weather  conditions.  When  a  flame  strikes  a  cooling  surface,  such 
as  a  metallic  plate,  combustion  may  also  be  incomplete.  The  complete  com- 
bustion of  carbonaceous  material  results  in  CO2,  the  incomplete  in  CO  plus 
other  by-products. 

CO  may  also  be  formed  by  the  de-oxidation  of  CO2,  when  the  latter  is 
passed  over  red  hot  coals  or  metal.  CO  formed  by  incomplete  combustion 
is  found  in  our  stoves  between  and  beneath  the  coals;  when  formed  by  de- 
oxidation,  on  the  surface  of  the  red  hot  coals. 

CO  is  also  found  in  the  after-damp  of  mine  explosions,  its  presence  being 
determined"  by  the  amount  of  methane  which  has  undergone  combustion. 
If  this  gas  is  present  in  volumes  over  9.5  per  cent.,  CO  is  formed  in  the 
after-damp. 

Fortunately  CO  is  usually  in  composition  with  other  gases,  such  as  CO2, 
hydrogen,  methane  and  illuminants,  some  of  them  imparting  an  odor  making 
the  presence  of  CO  detectable.  The  composition  of  these  various  gases,  as 
used  industrially,  will  be  referred  to  later. 

TOXICOLOGY 

From  the  view  point  of  the  industrial  hygienist,  or  occupational  disease 
physician,  CO  is  the  most  important  toxic  gas,  being  not  only  highly  toxic, 
but  used  extensively  in  our  various  industries.  Gruber^  says  that  the  limit  of 
toxicity  is  0.02  per  cent.  A  volume  of  air  containing  o.oi  per  cent,  may 
cause  distress,  headache,  nausea,  and  other  phenomena.  Others  say  that 
symptoms  will  not  be  produced  until  0.05  per  cent,  of  the  gas  is  present.  The 
point  of  toxicity  will  vary  in  individuals.  This  has  been  accurately  proved 
by  Haldane'^  in  humans  and  animals.  From  experiments  made  by  Sir 
Humphrey  Davy  it  is  recorded  that  about  0.08  gram  (about  12  grains)  of 
CO  is  fatal  to  a  man  of  154  lb.  weight  (Peterson  and  Haines).  The  blood 
is  capable  of  carrying  i  liter  of  oxygen  or  i  of  CO.     As  a  matter  of  fact  such 


46  OCCUPATIONAL   INTOXICATIONS 

will  never  occur,  since  we  never  find  a  saturation  of  the  hemoglobin  over  83 
per  cent,  in  fatal  cases.  It  is  well  known  that  an  air  volume  containing  i.o 
per  cent,  of  CO  is  considered  as  having  moderately  rapid  fatal  tendencies. 
In  the  Snaefell  Mine  Disaster,^  Dr.  J.  S.  Haldane  and  his  co-workers  observed 
that  the  mine  air  contained  1.07  per  cent.  CO. 

The  gas  acts  rapidly  with  no  irritation  to  the  respiratory  tract,  and  also 
because  of  its  inodorous  quality  its  presence  if  often  unknown.  A  case  is 
recorded  by  Sonnenschein  of  a  chemist  who,  by  a  single  inhalation  of  an  at- 
mosphere laden  with  the  gas,  fell  backward  as  if  struck  by  lightning. 

CO  is  more  toxic  for  certain  animals  than  for  others.  Birds  die  instantly 
in  an  atmosphere  containing  5  per  cent.  CO.  It  is  said  that  mice  are  still 
more  susceptible  to  the  gas.  If  CO  is  present  in  toxic  doses  it  will  affect 
mice  sooner  than  humans.  Haldane^  has  made  use  of  this  information, 
applying  it  to  safety  practice  in  the  mining  industry.  This  is  a  cheap 
and  simple  safety  precaution  which  can  be  made  use  of  in  our  mines. 

An  interesting  case  is  reported  by  Jeffries^  of  a  person  and  a  linnet  who 
were  overcome  by  illumiiiating  gas  due  to  an  accidental  leakage.  Of  im- 
portance is  the  fact  that  the  human  was  found  in  coma  and  recovered, 
whereas  the  bird  was  found  dead. 

The  effect  of  CO  gas  varies  in  animals,  causing  convulsions  in  rats  and 
other  animals,  while  birds  die  failing  to  show  such  signs.  Incidentally, 
the  writer  might  make  mention  here  of  the  method  of  killing  vagrant  dogs  in 
Chicago  by  this  gas.  The  writer  has  on  several  occasions  killed  guinea-pigs 
by  thrusting  them  under  a  bell  jar  full  of  illuminating  gas.  It  took  but  3^ 
minute  for  the  pigs  to  topple  over,  followed  by  general  convulsions  and 
death  in  from  2  to  3  minutes. 

The  gas  is  toxic  to  the  human  whether  it  is  inspired,  swallowed  or  in- 
jected into  the  peritoneal  cavity.  The  CO  rapidly  unites  itself  with  the 
hemoglobin,  replacing  the  oxygen  and  forming  a  very  stable  compound 
known  as  carboxyhemoglobin.  The  aflSinity  of  the  hemoglobin  for  CO  is 
300  times  greater  than  the  affinity  for  oxygen  (Haldane).  This  substitu- 
tion of  CO  for  oxygen  deprives  the  blood  corpuscle  of  its  oxygen-carrying 
power. 

There  is  a  difference  of  opinion  as  to  whether  CO  merely  causes  internal 
asphyxia  by  reason  of  having  deprived  the  blood  corpuscle  of  the  hemoglobin 
element  and,  therefore,  its  oxygen-carrying  power,  or  whether  the  gas  also 
has  a  distinct  toxic  action  on  tissue. 

Haldane  refers  all  toxicity  of  the  gas  to  the  lost  oxygen  carrying  power 
of  the  hemoglobin,  pointing  out  that  a  saturation  of  20  per  cent,  will  cause 
dizziness  and  dyspnoea,  50  per  cent,  loss  of  consciousness,  80  per  cent, 
death.  He  points  out  that  such  is  due  to  an  internal  asphyxia  and  explains 
that  even  such  pathological  sequelae,  as  fatty  degeneration  of  vessels  and 
other  organs,  are  due  to  the  impoverished  red  blood  corpuscle.  To  sustain 
his  point  he  proves  by  experiment  that  animals  will  live  much  longer  and 


CARBON   MONOXIDE   POISONING  47 

will  tolerate  a  greater  quantity  of  carbon  monoxide  in  an  atmosphere  of 
oxygen  than  of  air. 

However  convincing  Haldane  may  be,  we  must  consider  the  question 
whether  there  is  some  other  toxic  value  in  carbon  monoxide.  Following 
CO  poisoning,  even  with  small  doses,  sequelae  frequently  occur,  particularly 
in  the  nervous  system,  in  which  there  are  definite  pathological  changes. 
Moreover,  the  gas  is  rapidly  narcotizing,  and  the  earliest  symptoms,  such 
as  the  weakness  in  the  lower  limbs,  are  strongly  suggestive  of  some  distinct 
toxic  action.  The  latter  opinion  of  the  toxic  action  of  CO  is  strongly  sup- 
ported by  Gruber  and  Kobert.^  The  writer  attempted  to  kill  guinea-pigs  in 
equal  volumes  of  CO  and  of  CO2  and  found,  of  course,  that  the  animals  died 
much  more  rapidly  in  CO  than  in  the  CO2.  But  the  error  in  this  experiment 
can  be  readily  seen,  since  it  is  evident  that  the  oxygen-carrying  power  of  the 
blood  could  have  been  much  more  rapidly  depleted  by  one  gas  than  by  the  other. 

The  question  of  toxicity  of  this  gas  is  an  interesting  one,  but  we  must 
leave  the  argument  in  the  hands  of  the  toxicologist.  The  writer  has  always 
leaned  to  the  opinion  that  CO  has  a  definite  toxic  action  on  tissue,  but 
recently,  owing  to  the  work  done  by  Haldane  and,  also,  because  of  the  work 
done  by  Dr.  Matthew  Karasek  and  the  writer,  in  which  it  was  demonstrated 
that  humans  subjected  continuously  to  this  gas  had  a  compensatory  poly- 
cythemia and  no  physical  disturbances,  the  w-riter  has  inclined  more  and 
more  to  Haldane's  views. 

The  CO  exactly  displaces  the  oxygen  of  the  hemoglobin,  forming  a  very 
stable  compound  which  is  probably  never  disassociated  until  the  blood 
corpuscle  meets  its  death  and  is  eliminated. 

ACUTE  CARBON  MONOXIDE  POISONING 

Acute  carbon  monoxide  poisoning  is  found  in  many  industries,  the  nature 
of  which  will  be  dwelt  upon  in  detail.  In  previous  work  on  industrial  "gas- 
sing" reference  has  been  made  to  nearly  all  the  industries  in  which  acute 
gassings"  occur,  but  the  special  points  of  danger  as  existing  in  each  have 
never  been  clearly  brought  out. 

Following  is  a  table  of  statistics  gathered  from  the  reports  of  the  Chief 
Inspector  of  Factories  and  Workshops,  England: 


Year 

Total 

CO  gas  poisoning 
fS^ce    P°--      Coal 

Other 

.Sul- 
phur- 
etted 
H 

CO 

•2 

CI 

i    Ni-       Di-    1 

I     1  trous    nitre  | 

1  fumeSjbenzoli 

Ben- 
zin 

Other 

0  « 

z- 

a3 

0  a 
2*" 

'c3 

0   OJ 

,Z"" 

Non- 
fatal 
Fatal 

0  a 

Z"" 

Fatal 
Non- 
fatal 

z"- 

Fatal 

Non- 
fatal 

Fatal 
Non- 
fatal 
Fatal 

-1 
Z^  fa 

^1 
Z^  fe 

1908 

49 

6 

23 

1 
'  3 

1 

1 

17 

2 

81 

I 

0  1 

7 

I 

I    ' 

4 

I 

0'     2       120 

2      0 

3     0 

1909 

i37 

6 

6 

0 

21 

4 

10  !  I 

0 

I 

3 

2 

0 

2 

I 

0  10       24       0 

0       I 

4     0 

1910 

44 

9 

12 

7 

25 

0 

4  |o 

3 

2 

2 

0 

I 

I 

2 

Oil      0 18     0 

0      0 

4     0 

1911 

S8 

6 

14 

2 

30 

I 

4     2 

10 

I 

6 

2 

0 

I 

5 

0  16       2  21    1  0 

21    j  0 

0     4 

1912 

77 

14 

28 

5 

15 

4 

27     2 

7 

3 

6 

0 

I 

2 

3 

0  II        I      9       0 

2       1 

I     I 

48  OCCUPATIONAL   INTOXICATIONS 

This  table  shows  that  gases  containing  carbon  monoxide  cause  more 
industrial  sicknesses  and  deaths  than  the  other  gases  referred  to.  The  greater 
number  of  CO  "gassing"  cases  occurred  from  producer  and  blast-furnace  gas. 
Those  not  thoroughly  acquainted  with  the  subject  are  confused  when  such  a 
variety  of  gases  are  mentioned  as  coal  gas,  producer  gas,  water  gas,  blast- 
furnace gas,  power,  suction,  Monde,  and  other  gases.  It  should  be  con- 
stantly kept  in  mind  that  they  all  contain  carbon  monoxide  in  varying  quan- 
tities, and  that  it  has  been  fairly  well  established  that  carbon  monoxide  is  the 
toxic  agent  in  all  these  gases.  Their  toxicity  will  vary  because  of  the  dif- 
ferences of  CO  content,  diffusibility,  and  also  because  of  their  different 
methods  of  production.  It  seems  that  the  above  tabulation  cannot  include 
cases  of  CO  poisoning  which  have  occurred  in  coal  and  other  mines.  Fol- 
lowing is  a  tabulation  of  the  industries  in  which  carbon  monoxide  poisoning 
has  been  observed. 

The  manufacture  of  steel: 

1.  From  blast-furnace  gas. 

2.  In  the  .engine  houses  and  boiler  rooms  and  where  blast-furnace  gas  is 
used  as  fuel. 

3.  From  producer  gas. 

The  use  of  power  or  producer  gas: 

1.  Smelters  of  zinc  and  other  ores. 

2.  Tin  can  manufacturers. 

3.  Foundries. 

4.  Glass  bottle  manufacturers. 

5.  Coke  by-product  concerns. 

6.  Chemical  companies. 

7.  Laundries. 

8.  Tailoring  concerns. 

9.  Letter  press  printing. 

10.  Laquering  stoves. 

11.  Book  binderies. 

12.  Box  making. 

13.  Metallurgical  plants. 

The  manufacture  of  illuminating  gas: 

1.  Carburetted  water  gas. 

2.  Coal  gas. 
Industries  using  ovens: 

1.  Smelters. 

2.  Brick  kilns. 

3.  Cement  kilns. 

4.  Bakeries. 

5.  Enameling  of  porcelain. 

6.  Miscellaneous. 


CARBON   MONOXIDE   POISONING  49 

Heating  and  steam  power  plants: 

1.  In  the  engine  rooms  of  large  vessels. 

2.  Fire  and  boiler  rooms  in  all  industries. 

Where  "gassing"  occurs  with  moderately  ill  effects: 

1 .  The  use  of  salamanders  in  drying  newly  plastered  and  painted  buildings. 

2.  Electro typers. 

3.  Stereotype,  monot\^e  and  linotype  rooms. 

4.  Canneries. 

5.  By  the  use  of  the  tailor's  goose. 

6.  Metal-casting  machines. 

7.  Heating,  soldering  and  other  metal  pots. 

8.  Mining — in  explosions. 

From  the  fumes  of  gasoline  engines : 
I.  Garages. 

WTiere  CO  is  used  in  preserving  fruit  and  vegetables: 
I.  Freight  cars. 

Industries  not  mentioned  can  be  readily  classified  in  above  scheme  of 
classification. 

THE  STEEL  INDUSTRY 

The  blast-furnace  gas  as  produced  in  the  average  American  stack  will  run 
an  average  composition  as  follows: 

CO  26.0    per  cent.  CH4  i.o  per  cent. 

CO2  11.12  per  cent.  N  57.0  per  cent. 

H  3.5    per  cent.           O  0.2  per  cent. 

C2H2  0.3    per  cent. 

This  gas  is  produced  in  the  blast  furnace  by  the  smelting  of  iron  ore, 
coke  and  limestone,  in  the  proportion  of  2000  lb.  of  ore,  2000  lb.  of  coke, 
and  800  lb.  of  limestone.  After  combustion  has  begun,  the  mixture  is 
blasted  by  means  of  heated  air,  which  is  heated  in  the  adjoining  stoves,  four 
to  one  furnace.  The  air  in  the  stoves  is  heated  by  means  of  blast-furnace 
gas.  The  gas  which  is  produced  in  the  blast  furnace  goes  up  the  stack  to 
the  top  from  where  it  is  led  by  a  pipe  through  a  dry  cleaner  or  dust  collector. 
From  here  it  goes  to  the  gas  washer,  which  allows  the  gas  to  ascend  through 
screens  of  dropping  water,  removing  thereby  that  dirt  not  caught  in  the  dry 
cleaner.  It  is  then  piped  in  an  overhead  main  to  two  points,  the  stoves,  and 
the  boiler  and  engine  houses.  There  are  four  stoves  for  each  furnace, 
two  being  used  only  at  one  time.  In  these  the  gas  derived  from  the  blast 
furnace  undergoes  combustion,  heating  the  air  which  is  also  drawn  through 
the  stoves.  That  portion  of  the  gas  which  is  piped  either  to  the  boiler  houses 
or  to  the  gas  engines,  goes  through  an  overhead  main  to  its  destination. 
Some  steel  companies  use  the  gas  in  boiler  houses  to  produce  steam;  others 
4 


50  OCCUPATIONAL   INTOXICATIONS 

explode  it  in  gas  engines.  Both  methods  produce  power,  wherewith  the 
converters,  rail  mills  and  other  machinery  is  operated. 

Changes  in  the  operation  of  the  blast  furnaces  are  constantly  occurring. 
A  new  method  of  gas  cleaning  is  being  adopted,  which  will  reduce  the  risk 
of  gas  poisoning.  Instead  of  using  a  dry  cleaner  which  needs  a  daily  attention, 
the  gas  will  be  treated  by  washing,  which  process  is  not  so  productive  of 
gas  poisoning. 

There  are  certain  places  along  the  gas  route  where  "gassing"  is  liable  to 
occur. 

The  tops  of  the  furnaces  have  always  been  considered  notoriously  danger- 
ous. This  is  not  so  true  to-day  as  it  was  lo  and  15  years  ago.  The  modern 
blast  furnace  has  an  automatic  filler.  The  ore  goes  up  a  cable  hoist  and  is 
dumped  into  a  bell  valve.  Formerly  three  to  four  men  were  constantly 
required  at  the  top  of  a  furnace.  At  present  only  "cleaners"  or  "sweepers," 
"sailors"  and  "riggers,"  needed  in  urgent  repair  work,  are  required  to 
ascend  to  the  top  while  the  furnace  is  in  operation,  and  then  only  for  20 
minutes  every  12  hours.  Before  going  up  on  a  furnace,  the  foreman  is 
notified  and  attends  to  all  proper  safety  precautions.  No  man  is  ever  al- 
lowed alone  on  the  furnace. 

The  "mantle"  above  the  bustle  pipe  is  nearly  as  dangerous  as  the  top. 
It  seems  impossible  to  prevent  leakage  of  gas  through  the  walls  of  the  furnace, 
which  generally  occurs  in  a  belt  around  the  furnace  about  12  ft.  from  the 
ground,  including  the  area  called  the  mantle  or  platform,  running  around 
the  furnace.  Here  the  gas  is  found  frequently  in  sufi&cient  quantities  to 
maintain  continuous  combustion  when  ignited.  On  the  other  hand,  if  the 
gas  remains  unignited,  especially  on  rainy  days,  it  affects  those  on  the 
casting  floor. 

The  great  danger  about  the  stoves  is  at  the  enormous  burners  from 
adverse  draft  or  puff-back  of  unconsumed  gas  and  also  from  leakage.  A 
special  danger  exists  during  the  cleaning  out  of  a  stove  through  one  opening 
while  the  gas  is  burning  at  the  other. 

Another  source  of  "gassing"  is  in  cleaning  out  cold  mains  or  pipes,  be- 
cause the  gas  remains  inert  in  the  flue  dust  and  is  liberated  in  the  atmos- 
phere upon  being  disturbed.  This  is  done  less  frequently  at  present,  be- 
cause of  newer  methods  of  flushing  the  mains  with  water.  In  the  old-style 
furnaces,  where  the  mains  were  underground,  cleaning  was  a  very  dangerous 
operation.  A  series  of  pipes,  called  boot-legs,  descending  from  the  overhead 
main  on  its  way  to  the  engine  and  boiler  houses,  is  another  source  of "  gassing  " 
during  cleaning  time. 

In  the  boiler  house  the  same  danger  of  puff-back  is  present  as  at  the 
stoves,  except  in  the  later  make  of  boilers,  which  have  the  entering  flue 
burners  sealed  into  the  brickwork,  and  receive  air  from  a  point  about  2  ft., 
below.  This  type  of  boiler  we  saw  only  in  the  Illinois  Steel  Company's 
alternating-current    boiler   house.     With  this  kind  of  furnace  an  explosion 


CARBON   MONOXIDE   POISONING  5 1 

may  occur,  if  the  gas  is  carelessly  turned  on  too  rapidly  at  first.  During 
the  investigations  many  flues  with  large  leaks  or  rents  were  noticed,  either 
discharging  the  gas  under  pressure  into  the  boiler  room,  or  plugged  indiffer- 
ently with  clay  stoppers.  Cleaning  out  the  boilers  frequently  gives  rise  to 
"gassing,"  both  in  the  removal  of  debris  from  the  fire-box  and  space,  and 
from  the  boiler  drum. 

The  dry  cleaner  is  opened  daily.  "Gassing"  may  also  occur  from  this 
procedure. 

Accidental  leakage  usually  occurs  in  the  basement  of  the  gas-engine  house. 
The  men  who  work  above  the  engines,  such  as  oilers,  often  complain  of  head- 
ache, especially  after  having  worked  above  the  engines  for  a  prolonged  period. 
In  one  steel  mill  an  engineer  was  found  dead  on  the  bed  of  an  engine.  The 
coroner's  verdict  was  CO  poisoning. 

It  is  relevant  to  state  here  that  the  experience  of  the  writer  and  the  re- 
ports of  the  English  Factory  Inspector  coincide  in  regard  to  the  usual  occur- 
rence of  "gassing"  in  the  steel  mills.  A  great  many  occur  during  cleaning 
operations,  when  the  furnace  and  mains  are  not  in  operation.  Even  after  air 
has  been  driven  through  these  mains,  CO  lying  inert  in  the  flue  dirt  is  liber- 
ated when  cleaning  operations  are  conducted.  From  a  review  of  the  English 
Factory  Inspector's  reports,  it  can  be  seen  that  out  of  68  cases  of  carbon 
monoxide  poisoning  which  occurred  in  blast  furnace  work,  23  cases  repre- 
senting 33  per  cent,  of  the  total  number  occurred  during  cleaning  cold  mains 
or  furnaces. 

The  most  exposed  to  blast-furnace  gas  are  cleaners  of  cold  mains,  repair 
men  such  as  "riggers"  or  "sailors,"  oilers,  and  sweepers. 

Since  "gassing"  may  occur  anywhere  along  the  gas  route,  we  will  next 
mention  other  less  common  sources  in  the  regular  routine  of  furnace  operation. 
Structural  iron  men  have  been  "gassed,"  while  rigging  up  a  smoke  stack  over 
an  open-hearth  shed  or  building,  or  while  working  on  buildings  in  the  vicinity 
of  the  furnace.  Men  in  supposedly  safe  places  are  sometimes  overcome  by 
vagrant  whiffs  of  gas  due  to  peculiar  atmospheric  conditions.  Men  have 
taken  stolen  naps  alongside  the  blast-furnace  stoves  with  fatal  consequences. 
Then  there  occur  freak  "gassings"  which  even  the  most  expert  safety  man 
would  never  anticipate. 

The  majority  of  steel  mills,  while  obtaining  most  of  their  gas  from  the 
blast  furnaces,  find  it  necessary  to  operate  one  or  more  producer  gas  furnaces 
for  the  purpose  of  supplying  power  to  such  parts  of  their  plant  where  blast- 
furnace gas  is  not  available.  Most  of  these  furnaces  being  located  in  the 
open  are,  therefore,  seldom  the  cause  of  acute  CO  poisoning. 

In  this  connection  it  is  well  to  state  that  "gassing"  is  not  only  the  cause 
of  such  disturbances  as  drowsiness,  coma,  and  other  signs  of  gas  poisoning, 
but  is  also  the  cause  of  serious  accidents,  such  as  result  from  falls  after  having 
been  overcome  by  gas,  or  from  burns  due  to  gas  explosions.     Burns  resulting 


52 


OCCUPATIONAL   INTOXICATIONS 


from  explosions  have  occurred  in  and  about  gas  stoves  and  in  boiler  houses 
of  steel  mills. 

The  following  table  illustrates  the  result  of  our  investigation  concerning 
the  incidence  of  "gassing"  and  also  the  gas  route: 


Source  of  gas 

No.  of  men 
employed 

Fatal 
cases 

Severe  cases 
per  year 

Mild  cases 
per  year 

Blast  furnaces 

QOO 

13    during 
past  4  years 

65 

216 

Boiler  houses 

212 

I 

55   estimated 
from  findings 

Gas  engine 

42 

I  in  1910 

4 

Variable 

Open  hearths 

24 

I 

Variable 

GAS  ROUTE 


Leakage  in 
Loading 


"Stoves" 


^     f 


Blast 
Furnace 


Bustle 


and  other 
pipes 


Gas       ' 

Scrubbers  (■ 


Gas 

Washer 


I r 


Gaso- 
meter 


Boiler  House 


Engines 


Gas  poisoning  and  accidents  due  to  gas  in  steel  mills  have  in  the  past 
decade  or  two  shown  a  decided  decrease  for  the  following  reasons. 

New  and  modern  types  of  furnaces  have  been  installed.  Automatic 
charging  of  furnaces  has  eliminated  those  men  who  formerly  were  stationed 
at  the  tops  of  the  furnaces.  The  modern  furnace  is  of  more  substantial 
and  heavier  construction  with  a  view  of  accommodating  more  plates  and 
fire-brick.  Overhead  mains  have  replaced  underground  mains.  Moreover, 
underground  pits  have  been  done  away  with.  Safety  organizations  of 
the  steel  companies  have  adopted  suitable  safety  rules,  which  incorporate 
the  following  ideas:  No  man  is  allowed  upon  any  furnace  alone;  repairs 
must  be  undertaken  by  two  or  more  men;  a  watcher  must  accompany  every 
workman  in  any  place  of  hazard;  special  placards  and  transportable  danger 
signals  are  placed  in  the  danger  zone  (see  pictures  exhibiting  character  of 
signs  used). 

ILLUMNIATING  GAS  INDUSTRY 

Two  distinct  types  of  gas  are  used  for  illuminating  purposes,  water  and 
coal  gas.  Following  is  an  average  of  tests  made  of  the  composition  of  water 
and  coal  gas: 


CARBON   MONOXroE   POISONING  53 


Water  gas 

(carburetted), 

per  cent. 

Coal  ga 
per  cer 

300 

6-7.0 

30.00 

0.0 

12.00 

50 

31  s 

46.0 

18.0 

40.0 

o-S 

O-S 

4-5 

2.0 

C02 

CO 

Light  oils 

m 

CH4 

o 


The  use  of  water  gas  is  prohibited  in  many  cities  necessitating  the  use 
of  coal  gas.  In  certain  cities  of  England  the  use  of  a  gas  containing  over 
14  per  cent,  of  CO  is  forbidden  for  illuminating  purposes.  A  review  of  gas 
poisoning  shows  a  considerably  greater  number  of  "gassings"  occurring  in 
cities  using  water  gas  than  where  coal  gas  is  used.  The  illuminating  gas  in- 
dustries in  Chicago  employ  about  7000  men,  of  which,  however,  only 
2000  to  2500  are  exposed  to  the  gas.  These  men  are  engaged  in  operating 
the  various  stations  where  the  gas  is  manufactured,  in  repairing  of  leakages 
in  mains,  and  in  construction  of  new  mains. 

In  order  to  give  a  clear  understanding  of  the  dangers  of  "gassing"  the 
process  of  manufacture  is  described  here.  A  charge  of  coke  is  blasted  in  the 
generator,  this  part  of  the  process  being  called  the  "blow."  Steam  is  then 
blown  in,  forming  what  is  then  known  as  blue  water  gas,  which  has  43  per 
cent.  CO.  The  gas  is  next  carburetted  by  the  addition  of  pre-heated  gas 
oils,  reducing  the  CO  content  to  about  30  per  cent.  After  being  carburetted 
the  resulting  gas  is  passed  through  what  is  known  as  the  superheater,  which 
consists  of  a  checker  work  of  brick,  heated  so  as  to  fix  the  constituents  of 
the  gas.  From  here  the  gas  is  led  through  a  main  to  a  condenser,  which  cools 
and  to  a  certain  extent  mechanically  cleans  the  gas.  From  there  the  gas 
passes  to  the  shaving  scrubbers,  which  removes  most  of  the  remaining  tar. 
From  here  the  gas  is  passed  through  large  boxes,  containing  hydrated  FeOo, 
which  removes  sulphur  compounds  and  all  remaining  tar.  Having  been 
purified,  the  gas  is  metered  and  passed  into  large  tanks,  a  common  sight  in 
larger  cities,  where  it  is  ready  for  distribution  to  the  consumer. 

Up  to  this  point  accidental  leakages  may  occur,  causing  "gassing." 
Again  the  men  are  sometimes  gassed  while  cleaning,  especially  about  the 
generators,  mains  and  oxide  box. 

Gas  mains  are  often  laid  in  our  streets  parallel  to  a  sewer  or  an  electric 
conduit.  Therefore,  "gassing"  occurs  not  only  to  the  men  who  work  on  the 
gas  mains,  but  also  to  the  municipal  sewer  and  water  pipe  extension  crews, 
and  to  members  of  telephone,  telegraph,  and  electric  lighting  gangs.  The 
writer  has  personally  assisted  in  rescuing  from  a  manhole  two  repair  men  who 
had  been  overcome  by  gas  escaping  from  a  defective  main  while  repairing 
an  electric  connection. 


54  OCCUPATIONAL   INTOXICATIONS 

PRODUCER  GAS 

Producer  or  power  gas  is  used  in  the  industrial  world  to  generate  power  by 
means  of  a  gas  engine,  to  be  used  as  fuel  in  producing  steam  and  electricity 
or  for  heating  purposes.  The  industrial  use  of  producer  gas  is  increasing 
rapidly.  Therefore,  various  types  of  this  gas  are  manufactured.  Any  kind 
of  carbonaceous  material  can  be  used  for  rnaking  producer  gas.  The  most 
commonly  used  material  is  coal.  In  some  types  straight  distillation  occurs 
while  in  others  steam  is  used  as  part  of  the  manufacturing  process.  Thus 
the  composition  of  the  gas  will  vary  depending  upon  the  method  of  manu- 
facture. According  to  some  methods  the  gas  is  produced  by  suction,  to 
others  by  blasting  the  air.  Common  names  for  producer  gas  are:  power  gas, 
suction  gas,  Monde  gas,  and  wood  gas.  An  average  composition  of  producer 
gas  is  as  follows: 

Per  cent. 

CO 23.0 

C02 8.0 

H..... II. o 

C2H4 0.2 

CH4 0.2 

N 57-1 

0 0.2 

The  Enghsh  reports  show  a  large  number  of  "gassings"  from  producer 
gas.  The  accidents  depend  on  the  situation  of  the  generator,  on  whether 
suction  or  pressure  is  used  in  making  the  gas,  and  on  the  general  safety  rules 
followed.  A  producer  in  an  out-door  location  is  naturally  not  as  dangerous 
as  one  placed  in  an  irtclosure.  Producer  gas  is  used  in  metallurgical  plants, 
by  glass  makers,  for  heating  stereotype,  linotype  and  monotype  kettles, 
the  iron  in  tailoring  establishments  for  pressing  clothes,  in  laundries,  book 
binderies,  smelters,  laquering  stoves,  and  numerous  other  fields  of  industry. 

INDUSTRIES  USING  OVENS 

Ovens  are  used  in  various  trades  for  divers  purposes,  such  as  in  the  melt- 
ing of  ore,  enameling  of  porcelain  and  plumbing  supplies,  and  enamel  ware, 
in  bakeries,  chemical  companies,  and  in  other  industries.  Carbon  monoxide 
poisoning  is  not  common,  because  of  the  ease  with  which  a  discharge  of  gas 
into  a  room  can  be  prevented.  The  preequisites  of  preventing  CO  poisoning 
from  an  oven  are  a  good  draft  through  an  efficient  chimney,  and  care  in  keep- 
ing the  stove  door  closed.  Weather  conditions,  such  as  a  low  barometric 
pressure,  demand  extra  care  in  operating  an  oven.  Most  cases  on  record  have 
been  due  usually  to  gross  carelessness. 

FIREMEN  AND  BOILER  OPERATORS 

The  United  States  Navy  Surgeons  have  found  symptoms  indicative  of 
carbon  monoxide  poisoning  among  firemen  and  stokers  on  warships,  but  have 


CARBON   MONOXIDE   POISONING  55 

failed  to  ascertain  whether  caused  by  high  temperatures  or  CO  gas.  The 
location  of  boiler  rooms  on  large  sea-going  vessels  below  the  water  line  makes 
ventilation  and  fresh  air  a  tedious  problem.  Again  it  might  be  said  that  CO 
poisoning  in  this  line  on  land  is  usually  due  to  negligence  in  operation. 

MELD  FORMS  OF  "GASSING" 

Mild  forms  of  "gassing"  occur  in  such  concerns  where  fuel  is  burnt  in 
small  quantities  without  an  outlet  to  the  outside  air.  We  find  this  to  be 
true  of  salamanders,  w^hich  are  used  for  drying  the  plaster  and  paint  in  new 
buildings.  Other  instances  to  be  classified  under  this  caption  include  electro- 
plating, electrot>'ping,  stereotyping  and  linotyping,  machine  casting  of  metal, 
can  manufacturing  and  soldering.  One  case  of  severe  "  gassing  "  was  brought 
to  the  attention  of  the  writer,  as  Medical  Director  of  the  Ilhnois  Department 
of  Factory  Inspection.  A  painter,  upon  entering  the  room  in  which  he  in- 
tended to  work,  was  suddenly  overcome  by  the  fumes  of  a  salamander.  His 
companion  made  a  prompt  rescue,  but  became  partially  affected  by  the  gas, 
producing  headache  for  several  days,  nausea  and  malaise. 

MINING 

CO  poisoning,  severe  and  often  fatal,  is  found  in  mines  after  accidental 
explosions,  since  the  men  cannot  escape  rapidly  enough  from  the  poison-laden 
atmosphere.  Characteristic  of  mine  CO  is  that  it  is  usually  inodorous.  It 
occurs  most  frequently  in  the  after-damp,  the  gas  formed  by  the  explosion  of 
methane,  if  the  latter  exceeds  9.5  per  cent.  The  CO  in  mines  not  only  causes 
"gassing,"  but  often  also  serious  explosions  resulting  in  burns  and  injury  to 
the  body. 

FROM  THE  EXHAUST  OF  GASOLINE  ENGINES 

With  the  growth  of  the  gasoline  engine  for  motive  power,  as  in  the  auto- 
mobile and  the  gasoline  launch,  has  arisen  another  source  of  industrial  CO 
poisoning.  J.  N.  Schumacher,  chemist  for  the  city  of  Chicago,  upon  making 
a  series  of  gas  analyses  of  gas  collected  from  the  exhaust  pipes  of  motor  cars 
in  collaboration  with  the  writer,  has  obtained  the  information  that  an 
average  composition  of  exhaust  gas  is  as  follows: 

Per  cent. 
CO2 6.7 

CO 9.3 

0 1.4 

lUuminants 0.3 

N 82.2 

H 0.0 

These  analyses  were  not  made  from  the  first  sample  in  the  morning,  but  after 
the  motor  was  warmed,  which  condition  is  even  less  productive  of  CO  gas 
than  when  the  motor  is  cold.     Upon  investigation  the  writer  found  that 


56  OCCUPATIONAL   INTOXICATIONS 

headaches,  dyspnoea,  attacks  of  vertigo,  nausea  and  other  symptoms  were 
common  in  chauffeurs  of  large  taxicab  garages.  The  chauffers  unaccustomed 
to  continuous  doses  of  the  exhaust  gas  became  more  readily  affected  than  the 
machinists  and  others,  who  were  constantly  in  the  garages.  The  physician 
for  one  of  the  larger  concerns  informed  me  that  this  condition  is  more 
prevalent  during  the  cold  weather  season. 

One  morning  the  writer's  chauffeur  observed  that  his  companion,  who  had 
been  standing  near  the  back  of  the  car  while  the  engine  was  running,  stag- 
gered about  the  garage,  whose  windows  and  door  were  closed.  The  chauffeur 
opened  the  door  and  resuscitated  his  companion.  Although  not  in  coma, 
stupor  was  present  for  2  to  3  minutes.  The  victim  said  that  he  noticed  first 
a  pressure  in  the  temples,  then  a  weakness  in  the  legs,  and  blurring  before 
the  eyes.  Cases  of  death  have  occurred  in  private  garages,  where  the  occu- 
pant being  alone  was  unable  to  escape  from  the  CO  gas. 

Pathology. — The  post-mortem  findings  will  depend  on  the  length  of  time 
elapsing  between  death  and  autopsy,  and  also  on  the  suddenness  of  death. 
Following  a  very  quick  and  rapid  death,  the  cadaver  may  be  pallid  and 
cyanotic,  with  swollen  face  and  neck,  similar  to  death  from  CO2  gas.  Victims 
of  CO  gas  at  other  times  present  a  life-like  picture,  sometimes  with  rosy 
cheeks,  and  a  calm,  undisturbed  face,  as  if  there  had  been  no  death  struggle. 

Red  blotches  are  seen  on  the  face  and  body,  more  frequently  on  the  former. 
Such  findings  at  once  suggest  a  spectroscopic  or  Haldane  examination  of  the 
blood  for  CO.  These  blotches  are  hyperaemias  of  the  skin,  having  occurred 
with  vasomotor  paralysis,  though  sometimes  they  are  due  to  hemorrhages 
into  the  tissue. 

It  has  been  said  that  the  odor  of  gas  can  be  detected  from  the  mouth  of 
the  corpse.  If  this  does  occur,  death  must  have  been  recent,  and  the  gas 
must  have  had  other  constituents,  as  so  to  impart  an  odor.  This  may  be  true 
of  illuminating  gas  poisoning. 

Where  death  results  from  CO  poisoning  the  body  is  usually  remarkably 
well  preserved  and  retains  its  heat  for  an  unusually  long  time.  In  a  mine 
explosion  at  Whitehaven,^  England,  136  were  killed  and  found  5  months 
later  in  a  well-preserved  condition.  The  spectroscopic  characteristic  of  CO 
hemoglobin  was  obtained  in  the  blood  of  36  of  the  victims. 

In  the  interior  of  the  body,  attention  will  be  attracted  to  the  bright, 
cherry-red  color  of  the  blood  which  flows  freely.  This  peculiar  color  of  the 
blood  is  the  most  characteristic  post-mortem  sign  of  CO  death.  This  blood 
will  keep  in  excellent  condition  for  months,  for  purposes  of  examination,  if 
placed  in  a  well-stoppered  bottle.  Upon  examining  the  blood  by  means  of  a 
spectroscope,  the  two  bands  between  D  and  E  will  be  seen.  How  long  a  time 
after  death  a  determination  can  be  made  has  never  been  accurately  deter- 
mined, since  the  findings  depend  on  various  factors.  In  the  above-quoted 
Whitehaven  disaster  it  was  positively  proven  that  the  spectroscopic  bands 
can  be  seen  5  months  after  death.     The  conditions  underground  in  this  mine 


CARBON   MONOXIDE   POISONING  57 

may  have  been  more  favorable  for  preservation  than  if  death  had  occurred 
above  ground. 

CO  often  causes  a  rapid  fatty  degeneration.  This  may  be  observed  in 
the  heart  muscle,  liver,  kidneys,  vessel  walls,  and  other  tissues. 

Another  change  is  the  occurrence  of  small  hemorrhages,  usually  in  the 
brain,  though  also  in  the  muscles,  lungs,  and  other  tissues. 

The  heart  upon  being  opened  shows  bright  red  blood,  sometimes  fatty 
degeneration  in  the  musculature  and  in  the  walls  of  the  large  vessels. 

Broncho-pneumonia  is  common  in  those  having  died  from  the  effects  of 
CO  I  to  2  weeks  after  the  "gassing,"  the  pneumonia  being  a  complication. 
Upon  cutting  the  lungs,  the  characteristic  color  of  the  blood  can  be  observed. 

The  gastric  and  intestinal  mucosa  may  show  small  punctiform 
hemorrhages. 

Kidneys:  fatty  degeneration,  and  necrosis  in  the  convoluted'^  tubules. 

Skin:  herpes,  blebs,  pemphigus  and  gangrene. 

Carbon  monoxide  frequently  causes  pathological  changes  in  the  brain. 
Changes  have  been  observed  in  those  who  have  died  from  the  immediate 
effects,  and  among  those  who  have  died  from  psychoses.  Cerebral  hemor- 
rhages and  thromboses  in  cerebral  vessels  are  not  uncommon.  The  hemor- 
rhage may  be  extensive  or  there  may  be  numerous  punctiform  hemorrhages. 
Mott^  records  in  one  post-mortem  that  he  found  various  congestive  patches 
about  the  external  and  mesial  surfaces  of  the  hemispheres,  with  all  indications 
of  subpial  hemorrhages.  Autopsy  on  cases  from  psychoses  of  CO  gas  shows 
a  predilection  for  degenerations,  thrombosis,  encephalitis^  in  the  lenticular 
nucleus  and  the  optic  thalamus.  It  is  held  that  the  encephalitis  and  hemor- 
rhages sometimes  observed  in  gas  autopsies  are  due  to  the  rapid  fatty  degenera- 
tion, which  occurs  in  the  vessel  walls.  Kolisko^^  states  that  symmetrical 
softening  in  the  brain,  especially  the  lenticular  nucleus,  is  such  a  common 
finding  in  those  having  died  of  illuminating  gas  that  it  is  of  great  medico- 
legal importance. 

Another  common  finding  in  post-mortems  upon  "gas"  cases  is  extensive 
hemorrhage  into  the  serous  tissues,  pleura  and  peritoneum. 

In  summary  we  find  that: 

1.  Carbon  monoxide  produces  a  characteristic  blood  finding,  both  in 
gross  appearance  and  as  seen  by  the  spectroscope. 

2.  That  pathological  changes  in  the  tissue  are  not  constant. 

3.  That  broncho-pneumonia  is  a  frequent  pathological  complication. 

4.  That  CO  causes  fatty  degeneration  in  the  blood-vessels  and  other 
tissues,  and  extensive  hemorrhage  into  the  serous  tissues. 

5.  That  CO  has  a  predilection  for  causing  degenerations  in  the  brain, 
also  thrombosis,  encephalitis,  and  hemorrhages. 

Medico-legal  Question. — Can  carbon  monoxide  enter  the  body 
after  death? 

The  interesting  question  has  often  been  raised  whether  the  detection  of 


58  OCCUPATIONAL   INTOXICATIONS 

carbon  monoxide  in  the  blood  is  unmistakable  evidence  that  poisoning  by 
the  gas  had  taken  place,  or  whether  death  resulted  from  other  causes,  and 
that,  by  reason  of  the  corpse  having  been  placed  in  an  atmosphere  containing 
carbon  monoxide,  permitting  a  sufl&cient  quantity  of  the  gas  to  be  absorbed, 
so  as  to  cloud  the  diagnosis  of  suicidal  or  accidental  poisoning  or  death  from 
some  other  cause.  Whenever  carbon  monoxide  is  found  in  the  blood  the 
general  supposition  is  that  it  was  inhaled  into  the  lungs  during  life  and  entered 
the  circulation  in  that  manner.  In  1902  experiments  by  Wachholz  and 
Lenberger,^"  who  placed  the  bodies  of  stillborn  children  in  an  atmosphere  of 
pure  carbon  monoxide  gas,  showed  that  within  a  half  hour  the  deep  livid 
patches  observed  in  the  skin  of  the  cadavera  had  turned  to  a  red-rose  color. 
The  presence  of  carbon  monoxide  in  the  blood  was  determined  by  the  spec- 
troscope, even  as  late  as  7  days  after  the  immersing  process,  especially  in  the 
blood  removed  from  the  heart.  In  permitting  a  long  period  of  time  to  elapse 
between  death  and  the  placing  of  the  cadaver  in  the  gas  the  chances  of 
absorbing  carbon  monoxide  lessen.  Some  German  authorities,  as  Strassman 
and  Schultz,  venture  the  opinion  that  carbon  monoxide  enters  the  skin  and 
external  coverings  of  a  dead  person  and  penetrates  into  the  blood,  and  that 
the  quantity  of  carbon  monoxide  in  the  superficial  and  more  exposed  blood  and 
tissues  is  always  greater  than  that  found  in  the  deeper  and  more  central  parts. 

When  carbon  monoxide  is  present  in  the  blood  of  a  dead  person  it  is  of 
utmost  importance  to  determine  at  what  time  the  gas  penetrated — whether 
during  life  or  after  death.  In  the  post-morten  diffusion  of  the  gas  there  is 
a  well-defined  difference  between  the  anterior  portion  of  the  liver,  whose 
carbon  monoxide  contents  is  plentiful,  and  the  posterior  portion,  which 
contains  less  CO  and  is  of  a  deeper  color.  Statements  have  been  made  that 
this  difference  is  not  noticeable  when  death  has  resulted  from  poisoning. 
In  this  instance  the  blood  at  the  periphery  contains  more  carbon  monoxide 
than  the  deeper  parts  of  the  body.  Experiments  by  Strassman  and  Schultz 
upon  the  bodies  of  old  men  offer  evidence  that  there  was  no  part  of  the  body, 
practically  speaking,  into  which  carbon  monoxide  did  not  penetrate,  depending 
upon  the  length  of  exposure  to  the  gas.  These  experimenters,  too,  mention 
the  difference  between  the  anterior  and  posterior  portions  of  the  liver,  as 
stated  above,  also  that  in  cutting  through  the  tissues  the  blood  nearest  the 
skin  always  contained  the  greater  amount  of  carbon  monoxide.  In  a  case 
of  poisoning  by  inhalation  of  carbon  monoxide  such  a  difference  would  not 
occur,  since  the  blood  would  be  equally  affected  all  through  the  body. 
Failure^"  to  state  the  quantity  of  carbon  monoxide  recovered  in  the  blood 
greatly  weakens  the  argument  of  Strassman  and  Schultz.  The  point  in  this 
statement  will  be  clearer  when  attention  is  drawn  to  the  fact  that  very 
minute  quantities  of  carbon  monoxide  may  be  present  in  the  blood  in  normal 
conditions.  The  possibility  of  the  diffusion  of  carbon  monoxide  into  the  blood 
and  tissues  of  a  corpse  is  a  matter  of  great  importance  from  a  medico-legal 
point  of  view,  as  the  following  case  illustrates. 

Oliver^"  reports  a  German  case  of  a  woman  who  was  found  dead  in  her 


CARBON   MONOXIDE   POISONING  59 

room,  with  one  end  of  an  India-rubber  pipe  in  her  mouth  and  the  other 
attached  to  a  gas  pipe,  the  valve  of  which  was  open.  The  room  smelt 
strongly  of  coal  gas.  Everything  seemed  to  favor  the  theory  that  death 
was  suicidal,  but  at  the  last  moment  the  father  of  the  dead  person  intervened 
and  asked  for  a  delay  in  the  interment  as  he  believed  an  operation  for  the 
induction  of  abortion  had  taken  place  at  the  instigation  of  the  husband, 
and  that  in  order  to  raise  the  question  of  suicide  the  tube  had,  in  order  to 
mislead,  been  placed  in  the  woman's  mouth.  An  inquiry  was  ordered,  and 
Strassman  and  Schultz  found  that  no  abortion  had  taken  place,  and  that 
there  were  all  the  typical  signs  of  poisoning  of  carbon  monoxide. 

In  summary,  the  writer  believes  that,  if  a  body  is  examined  and  it  is 
found  that  all  the  organs  and  all  parts  of  the  organs  present  the  characteristic 
carbon  monoxide  pathologic  findings,  especially  in  the  liver,  and  that  if 
the  CO  saturation  of  the  blood  is  in  the  neighborhood  of  75  to  83  per  cent,  as 
determined  by  the  Haldane  method,  death  was  due  to  carbon  monoxide 
poisoning;  whereas,  such  cases  as  present  a  typical  and  a  symmetrical 
carbon  monoxide  pathological  finding  and  where  the  hemoglobin  saturation 
is  low,  reasonable  doubt  may  there  exist  as  to  the  cause  of  death. 

Symptomatology. — An  acute  carbon  monoxide  poisoning  will  vary  in 
intensity  upon  the  amount  of  CO  which  enters  the  blood,  and  upon  the 
rapidity  with  which  it  is  accomplished.  Other  determining  factors  are  the 
susceptibility  of  the  person  "gassed"  and  whether  pathological  accidents 
such  as  hemorrhage  occur  with  the  initial  insult.  Among  four  workmen 
who  seemed  exposed  to  equal  quantities  of  the  gas,  the  writer  observed  that 
one  was  in  deep  coma,  whereas  the  others  were  simply  in  stupor. 

Prodromata. — In  some  cases  of  "gassing"  the  victims  succumb  as  rapidly 
as  if  struck  by  lightning,  with  no  apprehension  of  its  presence  and  with  no 
prodromes.  The  coma  and  even  death  may  be  almost  immediate.  Out  of 
about  300  cases  of  industrial  gas  poisoning  comas  observed  the  writer  would 
say  that  about  one-third  occurred  without  prodromes.  Absence  of  prodromes 
is  especially  true  of  blast-furnace  gas  intoxication. 

Following  are  the  more  common  prodromes  of  carbon  monoxide  poisoning: 
a  throbbing  or  feeling  of  pressure  in  the  temples;  tinnitus  aurium;  distress 
in  the  epigastrium;  nausea,  sometimes  vomiting;  weakness  in  the  legs  together 
with  sluggishness  of  movement;  hallucinations  and  wild  mental  pictures; 
sometimes  convulsions;  a  severe  or  even  bursting  headache;  and  blurring 
before  the  eyes. 

The  most  common  prodromes  are:  the  pressure  and  throbbing  in  the 
temples;  the  epigastric  pain;  and  the  weakness  in  the  lower  limbs.  The  latter 
is  often  described  as  a  "caving  in"  at  the  knees  and  an  inability  of  movement. 
Some  "gases"  are  able  to  move  away  and  escape,  others  seem  "glued" 
to  the  spot,  and  are  unable  to  conduct  locomotion.  From  the  prodromes, 
if  they  occur,  the  patient  lapses  into  somnolence,  then  into  coma. 

Dr.  C.  Le  Neve  Foster^  makes  some  interesting  statements  concerning  the 


6o  OCCUPATIONAL   INTOXICATIONS 

sensations  and  symptoms  experienced  upon  being  "gassed"  in  mine  air  con- 
taining about  1.07  per  cent.  CO. ;  "The  poison  took  effect  most  suddenly.  .  .  . 
I  felt  decidedly  queer,  when  I  reached  the  level  and  thought  that  a  drop  of 
brandy  might  revive  me.  I  took  out  my  little  brandy  flask,  but  already  my 
fingersseemedincapableof  doing  the  work  properly.  .  .  .  Every  thing  seemed 
in  a  whirl,  and  the  atmosphere  seemed  to  be  a  dense  white  fog.  ...  A 
curious  fact  is  that  we  all  sat  without  moving  or  trying  to  escape ;  the  foot  of  the 
ladder  was  close  by,  yet  none  of  us  made  any  effort  to  get  to  it  and  even  ascend 
a  single  rung."  In  writing  a  note  of  farewell  to  his  family  he  states:  "I 
frequently  wrote  the  same  sentence  over  and  over  again."  This  reiteration 
of  words  and  syllables  is  occasionally  observed  among  the  early  symptoms 
of  gas  poisoning. 

Other  prodromes  sometimes  observed  are:  a  dryness  of  the  throat,  back- 
ache; heart  fluttering  or  palpitation;  and  sensations  of  chilliness. 

CARBON  MONOXIDE  COMA 

When  the  narcotic  action  of  the  gas  continues,  the  victim  becomes 
comatose.  The  usual  text-book  pictures  of  gas  coma  do  not  always  occur. 
We  are  taught  to  look  for  rosy  cheeks  and  bright  red  lips.  On  the  other 
hand,  cyanosis,  palor  and  distorted  facial  expressions  are  frequently  met  with. 
Nevertheless,  in  a  great  number  of  cases  red  blotches  and  areas  of  hyperaemia 
form  upon  the  skin  and  the  lips  and  conjunctiva  are  a  bright  red.  The  writer 
has  observed  that  these  typical  gas  comas  are  more  often  found  in  illuminating 
and  coal-gas  poisoning  than  in  those  which  occur  from  the  other  industrial 
gases. 

The  coma  in  the  average  industrial  "gassing"  is  milder  than  those  ob- 
served by  physicians  in  the  average  illuminating  gas  poisoning  where  such  has 
occurred  accidentally  or  with  suicidal  intent.  That  a  far  lesser  number  of 
"gassings"  accompanied  with  coma  take  place  may  be  gathered  from  the  fact 
that  out  of  281  "gassings"  about  a  blast  furnace  only  65  were  actually  coma- 
tose, whereas  216  never  entertained  more  than  a  stupor  or  the  prodromal 
symptoms. 

The  reddened  areas  or  blotches  are  due  to  vasomotor  disturbances  caus- 
ing local  hyperasmias  and  sometimes  from  actual  hemorrhage  into  the  skin. 
They  are  most  commonly  observed  on  the  face. 

The  pulse  is  at  first  full  and  slow  with  a  rise  of  blood  pressure.  Later 
as  the  coma  deepens  or  as  the  patient  survives,  the  pulse  becomes  feeble  and 
rapid.  Rapidity  of  pulse  or  tachycardia  will  continue  for  several  days  after 
recovery  from  the  coma.  The  respirations  are  at  first  deep,  stertorous,  later 
weak  and  rapid. 

Hyperpyrexia  occurs  most  commonly,  the  temperature  ranging  from 
100°  F.  to  104°  and  105°.  Temperature  is  often  an  indication  of  pneumonia. 
If  the  rise  is  sudden  after  the  patient  has  recovered  from  the  coma,  or  if  it 


CARBON   MONOXIDE   POISONING  6 1 

occurs  during  the  coma  it  is  suggestive  of  brain  insult  such  as  hemorrhage, 
or  thrombosis.  Dr.  W.  Oilman  Thompson^'  states  that  in  nearly  all  comatose 
cases  observed  by  him  there  was  an  elevation  of  body  temperature,  lasting 
from  a  day  to  a  week  or  more.  In  some  cases  there  was  a  preliminary  fall  to 
96°  or  97°F,  The  writer  observed  that  similarly  to  fatal  cases  of  brain  injury, 
such  as  cerebral  hemorrhage,  sunstroke  and  skull  fracture,  there  is  in  fatal 
cases  of  gas  comas  an  antimortal  rise  of  temperature  in  many  cases  from  107° 
to  iio°F. 

The  odor  of  gas  can  sometimes  be  detected  on  the  breath  early  in  the 
coma.  This  occurs  more  often  in  illuminating  gas  intoxication  than  with 
those  "gassed"  industrially.  The  odor  is  not  that  of  the  gas,  but  rather  of  a 
characteristic  odor  familiar  to  the  physician  meeting  frequently  with  gas 
comas. 

Nervous  phenomena  observed  are  initial  convulsions,  twitchings  of 
muscles  during  the  coma,  and  absence  of  the  deep  reflexes  (depending  on  the 
depth  of  the  coma).     Rare  signs  are  nystagmus  and  strabismus. 

Other  incidents  of  gas  coma  are  involuntaries,  Cheyne  Stokes  respira- 
tions, local  oedema,  hemorrhages  in  the  sclera  and  conjunctiva. 

No  diagnostic  aid  is  given  in  a  urine  analysis.  Albuminuria  is  of  no 
value  nor  is  melituria.  Four  out  of  five  successive  "gassing"  cases  reported 
by  a  Oerman  clinician  have  had  a  glycosuria.  Dr.  Herbert  S.  Carter,  who 
made  urine  analyses  for  Dr.  W.  Oilman  Thompson^^  in  five  non-fatal  cases, 
found  an  increase  of  chlorides  and  urea. 

The  duration  of  a  coma  varies  from  a  few  minutes  to  several  days. 
Comas  lasting  over  48  hours  are  usually  fatal,  either  directly  or  from  a  com- 
plicating pneumonia.     Of  course  this  is  the  probability,  not  the  rule. 

A  positive  diagnosis  of  gas  cannot  be  made  from  any  of  the  above-men- 
tioned symptoms  and  physical  signs.  The  clinical  observations  of  a  coma- 
tose patient  may  disclose  a  bright  redness  of  the  blood,  cherry  red  lips,  red 
blotches  on  the  skin,  and  the  odor  of  gas  on  the  breath.  Still,  the  most 
determining  factor  in  the  diagnosis  is  the  history  and  especially  the  examina- 
tion of  the  blood. 

Analysis  of  the  Blood. — Carbon  monoxide  in  the  blood  may  be  de- 
tected by  (i)  a  spectroscopic  examination,  (2)  Haldane's  method,  and  (3) 
various  other  color  determinations. 

Spectroscopic  Examination. — The  spectroscopic  examination  of  the  blood 
will  positively  tell  whether  CO  is  in  combination  with  the  hemoblogin  of  the 
red  blood  corpuscle.  Hoppe-Seyler  first  described  the  carboxyhemoglobin 
picture  in  1865.  Upon  placing  a  sample  of  CO  blood  in  a  small  glass  tube  in 
the  spectroscope,  two  absorption  bands  are  seen  in  that  portion  of  the 
spectrum  described  as  D-E.  These  bands  which  are  found  between  D  and 
E  have  nearly  the  same  width  and  are  of  the  same  intensity.  They  are 
similar  to  the  bands  of  oxyhemoglobin,  the  band  nearer  to  D  almost  coin- 
ciding, the  other  being  nearer  the  violet  end  of  the  spectrum  than  in  oxy- 


62  OCCUPATIONAL   INTOXICATIONS 

hemoglobin.  The  distance  between  the  bands  of  carboxyhemoglobin  is  also 
slightly  wider  than  the  distance  between  the  two  bands  of  oxyhemoglobin. 

When  the  blood  has  a  saturation  of  27  per  cent.  CO,  the  addition  of  a 
blood-reducing  agent,  as  a  drop  or  two  of  a  solution  of  crystallized  ammonium 
sulphide,  does  not  convert  or  reduce,  the  carboxyhemoglobin  to  one  of  re- 
duced hemoglobin.  This  differentiates  carboxyhemoglobin  from  oxyhemo- 
globin.    The  reduced  hemoglobin  has  only  one  band  in  the  D-E  space. 

Blood  exposed  to  the  air  for  a  week  often  loses  its  CO  spectroscopic 
picture,  whereas  blood  sealed  in  a  glass  tube  remains  undisturbed  for  a  long 
time  for  purposes  of  examination. 

In  a  non-fatal  case  of  carbon  monoxide  poisoning  the  characteristic  spec- 
troscopic blood  cannot  be  seen  after  several  days.  Kobert^  mentions  the 
report  by  Wacholz  of  carbon  monoxide  in  the  blood  7  days  after  exposure 
to  the  gas;  Fischbein  reports  one  of  5  day's  duration.  In  the  cadaver  the  CO 
may  persist  for  spectroscopic  examination  for  a  much  longer  time,  as  in  the 
Whitehaven  disaster  where  it  was  observed  5  months  after  death  had  occurred. 

The  Haldane  Method. — The  principle  of  this  method  is  color-metric 
comparison. 

A  few  cubic  centimeters  of  normal  blood  solution  are  shaken  to  satura- 
tion with  a  like  volume  of  air  which  then  is  ready  to  be  tested  for  CO. 
A  known  volume  of  normal  blood  solution  is  then  taken  and  standardized 
and  carmine  added  from  a  burette  until: 

1.  The  quality  of  pinkness  is  reached,  similar  to  the  solution  saturated 
with  the  air  sample;  and, 

2.  Equality  is  reached  for  the  same  blood  solution  fully  saturated  with  CO 
is  reached. 

From  the  two  results  the  percentage  saturation  of  the  blood  solution  with 
the  sample  of  air  is  deduced;  and  from  this  the  percentage  of  CO  in  the  air 
sample  can  be  calculated.  This  method  is  well  adapted  to  samples  of  air  or 
other  gases  containing  0.2  or  less  of  CO,  showing  its  degree  of  delicacy. 

This  test  can  be  used  both  to  analyze  a  sample  of  air  for  the  presence 
of  CO  and  also  the  blood  for  its  CO  saturation. 

Other  Chemical  Tests} — Blood  rich  in  CO  when  boiled  yields  a  brick-red 
mass;  ordinary  blood  becomes  brown  (Hoppe-Seyler). 

Ten  cc.  of  a  2  per  cent,  solution  of  blood  with  carboxyhemoglobin  will 
yield  a  bright  red  color,  if  2  cc.  of  yellow  ammonium  sulphide  and  30  percent, 
acetic  acid  are  added;  normal  blood  under  the  same  reagents  gives  a  green 
precipitate  (Katagama). 

If  a  carboxyhemoglobin  blood  is  added  to  diluted  hydrogen  sulphide 
water,  drop  by  drop,  a  bright  red  color  is  produced;  with  normal  blood  a  bright 
green  (Salkowski). 

Normal  blood  when  shaken  with  one  or  two  volumes  of  a  solution  of 
sodium  hydroxide  of  1.3  specific  gravity,  becomes  black,  in  layers  greenish 
brown;  CO  blood  remains  red  like  red  lead  (Hoppe-Seyler). 


CARBON   MONOXIDE   POISONING  63 

A  mixture  of  calcium  chloride  and  sodium  hydroxide  gives  a  carmine-red 
color,  if  CO  is  present,  whereas  normal  blood  becomes  brown  (Eulenberg). 

Equal  quantities  of  blood  (2  cc.)  and  water  plus  3  drops  of  a  one-third 
saturated  solution  of  copper  sulphate  give  in  CO  blood  a  brick-red  precipi- 
tate, whereas  normal  blood  has  a  greenish-brown  color  (Zellski). 

Four  or  five  volumes  of  lead  acetate  solution  are  added  to  one  volume  of 
carbon  monoxide  blood  and  thoroughly  shaken  for  about  a  minute.  Such 
blood  retains  its  red  color;  normal  blood  under  similar  conditions  becomes  a 
bright  red  (Rubner's  test). 

Fischbein^^  states  that  the  test  suggested  by  Wetzel,  namely,  dilution  of 
the  blood,  one  part  to  four  with  water,  and  shaking  with  three  times  the 
volume  of  i  per  cent,  tannic  acid,  whereby  normal  blood  becomes  gray  and 
carbon  monoxide  blood  remains  red,  is  the  most  reliable  and  trustworthy  test 
in  the  presence  of  formaldehyde  (embalmed  bodies).  In  case  no  formalde- 
hyde is  present  Rubner's  test  yields  satisfactory  results,  except  that  it  does 
not  act  immediately  but  is  best  interpreted  after  several  days. 

Late  Symptoms. — When  a  person  wakes  from  gas  stupor  or  coma,  it  usually 
takes  from  2  to  3  days,  and  sometimes  longer,  for  restoration  to  a  normal 
condition. 

The  coma  leaves  the  patient  with  a  severe  headache  which  lasts  the  entire 
day  or  persists  for  one  or  more  days.  This  is  even  true  of  mild  industrial 
"gassings."  Moreover,  anorexia,  sometimes  nausea,  pains  in  the  limbs  and 
even  neuritis  follow  a  "gassing." 

Twenty-seven  men  were  critically  observed  for  i  week  following  a  blast- 
furnace intoxication.  One  man  who  had  been  hardly  "gassed"  suffered  a 
coarse  tremor,  anorexia  and  insomnia  for  3  days.  Tremor  of  the  tongue  and 
fingers  is  a  common  aftermath.  One  of  the  above-mentioned  27  was 
markedly  neurasthenic  for  i  week,  and  also  complained  of  anorexia  and 
insomnia.     Even  severer  after-effects  have  been  observed  by  other  physicians. 

Sequellae. — Among  the  sequellae  of  carbon  monoxide  poisoning  are: 
(i)  pneumonia,  (2)  psychoses,  (3)  paralyses,  (4)  skin  eruptions,  and  (5) 
gangrene. 

Pneumonia. — Broncho-pneumonia  frequently  terminates  a  gas  poisoning. 
It  occurs  both  during  the  coma  and  often  when  the  patient  seems  entirely 
recovered.  Thus  we  find  pneumonia  following  a  CO  intoxication  lasting 
from  2  days  to  2  weeks.  Conditions  which  favor  its  occurrence  are  the 
length  of  the  coma,  carious  teeth,  exposure  to  cold,  and  the  respiratory  ir- 
ritation of  the  gas  and  of  oxygen  used  in  resuscitation.  The  pneumonia  is 
commonly  of  the  "  schluck-pneumonie  "  type.  The  inordinate  use  of  oxygen 
has  been  thought  by  one  of  the  physicians  of  a  large  illuminating  gas  company 
to  be  a  respiratory  irritant  and,  therefore,  a  predisposing  cause  to  pneumonia. 
Perhaps  it  may  be  that  the  oxygen  was  inordinately  used  in  such  cases  where 
the  coma  was  deep,  as  pneumonia  might  have  occurred  also  without  using 
oxygen.  ' 


64  OCCUPATIONAL   INTOXICATIONS 

The  Psychoses. — Psychoses  must  not  be  interpreted  to  mean  those  milder 
phenomena  which  follow  "gassing"  immediately,  such  as  neurasthenia, 
muscular  twitchings,  insomnia  and  other  mild  neuroses.  Definite  mental 
disorders  have  been  reported  from  various  sources  in  the  literature  following 
carbon  monoxide  poisoning.  Sibelius^^  and  Stierlin^^  have  presented  this 
phase  of  the  subject  most  thoroughly  and  in  admirable  detail.  Others  who 
have  treated  of  carbon  monoxide  psychoses  are  Zangger,^*  Giese/^  Mott,® 
Libin,^  Weidner,^^  O'Malley,^®  and  Abrahamson.^^  Sibelius  classifies  this 
complication  as  (i)  psychoses  directly  due  to  CO,  (2)  psychoneuroses,  (3) 
emotional  psychoses,  (4)  traumatic  or  mixed  psychoses.  The  most  concise 
understanding  of  the  subject  for  the  industrial  hygienist  is  the  knowledge 
that  some  CO  psychoses  follow  "gassing"  immediately  and  that  others  have 
a  lucid  interval  of  from  2  to  3  weeks,  keeping  in  mind  that  actual  brain  lesions 
may  occur  due  to  CO,  causing  thrombosis  and  degenerations,  while  still  others 
might  be  traumatic,  precipitating  the  psychosis  where  the  victim  is  neuro- 
pathically  predisposed. 

How  commonly  do  we  find  psychoses  following  industrial  "gassing?" 
The  literature,  rich  in  descriptions  of  psychoses,  fails  to  show  any  attempt  at 
separating  those  cases  which  occur  industrially  from  those  chargeable  to 
neurotic  individuals  with  suicidal  tendencies.  The  writer  believes  that  if 
an  investigation  were  made,  few  cases  of  psychoses  following  industrial 
"gassing"  would  be  discovered.  Dr.  James  Burry,  Surgeon  in  Chief  of  the 
Illinois  Steel  Company,  in  his  extensive  experience  with  "gassing"  has 
never  observed  one  single  case  of  psychosis  undisputably  attributable  to 
carbon  monoxide. 

In  comparing  the  reported  psychoses  subsequent  to  carbon  monoxide 
poisoning,  no  two  cases  present  the  identical  clinical  picture.  We  find  that 
they  simulate  dementia  praecox,  acute  mania,  general  paresis,  Korsakow's 
syndrome  and  other  forms  of  dementia.  O'Malley's  case  had  amnesia, 
apathy,  stupor,  delirium  and  confabulation.  Giese^^  reports  a  case  having 
amnesia,  stupor,  and  a  resemblance  to  Korsakow's  syndrome,  terminating 
fatally.  Dr.  Alex  Scott  quotes  a  case  of  dementia  with  acute  mania,  of  8 
days'  duration,  with  recovery.  Dr.  Sanger  Brown,  of  Chicago,  also  reports 
a  case  with  both  retrograde  and  anterograde  amnesia  following  a  "gassing." 
The  patient  never  recovered  entirely  and  died  suddenly  8  months  after 
exposure  to  the  gas. 

At  this  point  the  writer  quotes  a  psychosis  which  occurred  to  a  young 
man  who  was  "gassed"  while  working  above  the  bustle  pipe  of  a  blast 
furnace,  where  he  was  found  in  deep  coma,  after  having  fallen  for  a  short 
distance.  He  remained  in  coma  12  hours  in  the  company's  hospital.  Sub- 
sequently he  became  delirious,  restless,  unable  to  deintify  relatives  and 
friends.  He  suffered  from  involuntaries,  muscular  twitchings  and  apathy. 
He  could  not  realize  what  had  happened  to  him.  When  the  delirium  ceased, 
he  remained  very  stuporous  for  several  weeks  in  the  hospital.     Above  in- 


CARBON   MONOXIDE   POISONING  65 

formation  was  obtained  from  relatives  and  hospital  physicians.  When 
first  examined  by  the.  writer,  this  patient  had  been  home  for  4  months. 
During  this  time  he  had  tried  to  work,  but  was  unable  to  find  his  way  about 
the  company's  plant  and  grounds. 

Following  facts  were  obtained:  The  patient  had  previously  been  an 
industrious  person.  He  used  whiskey  and  beer  moderately,  was  married, 
had  one  child  at  the  time  of  the  accident.  He  lived  alone,  having  previously 
acquired  s>-philis  from  his  wife.  A  Wassermann  test  was  medium  positive. 
At  the  time  of  examination  he  suffered  from  an  amnesia  which  was  charac- 
terized by  a  loss  of  memory  for  all  events  except  those  which  occurred  in  his 
childhood.  He  remembered  Dr.  Karasek  and  the  writer  at  intervals  of 
several  days,  but  in  many  other  instances  his  memory  lapsed  even  on  daily 
happenings.  Thus  he  had  a  retrograde  and  partial  anterograde  amnesia. 
He  could  not  orient  himself  on  the  streets  and  became  lost  even  though  a 
few  doors  from  his  home. 

His  reasoning  power  did  not  seem  affected.  He  understood  that  he  was 
sick,  was  able  to  talk  rationally,  and  identify  many  objects. 

His  speech  was  slow  andT  similar  to  a  paretic.  His  gait  was  slow  and 
awkward.  The  dynometer  showed  diminished  muscular  strength.  Reflexes 
were  normal,  the  patellar  being  sluggish. 

Although  this  case  showed  a  positive  Wassermann,  the  patient,  as  com- 
pared with  other  gas  psychoses  recorded,  evinces  a  great  similarity.  He  had 
an  amnesia,  loss  of  orientation,  and  other  signs,  which  appeared  suddenly 
upon  being  "gassed."  Moreover,  he  had  been  in  good  health  before  the 
accident. 

In  conclusion,  psychoses  upon  carbon  monoxide  poisoning  are  charac- 
terized: 

1.  That  they  occur  either  directly  after  or  at  a  shorter  or  longer  interval 
after  the  "gassing." 

2.  That  they  are  variable  in  t}'pe,  often  simulating  other  forms  of 
psychoses,  such  as  dementia  praecox,  general  paresis,  and  Korsakow's 
syndrome. 

3.  That  amnesia  or  a  loss  of  memory  is  the  most  common  finding  in  gas 
psychoses. 

4.  That  the  pathological  basis  is  brain  hemorrhages  and  thrombotic 
occlusions,  with  encephalitis  as  the  result  of  carbon  monoxide  poisoning. 

5.  That  the  majority  recover,  and  that  no  prognosis  can  be  divided  from 
the  character  of  the  psychosis. 

Cerebral  Hemorrhage. — Cerebral  hemorrhage  with  hemiplegia  is  sometimes 
the  result  of  an  acute  carbon  monoxide  poisoning,  due  to  the  rapid  fatty 
degeneration  of  the  blood-vessel  walls,  also  to  the  rise  of  blood  pressure  at 
the  onset  of  the  coma.  Such  hemorrhages  also  cause  other  forms  of  paralyses 
or  motor  disturbances.  The  EngHsh  Factory  Inspector  reports  the  case  of 
a  fatal  cerebral  hemorrhage  in  a  man  24  years  old,  who  while  cleaning  a  main 


66  OCCUPATIONAL   INTOXICATIONS 

was  "gassed."  In  connection  with  the  paralyses  occur  disturbances  of 
sensation,  as  paraesthesias,  analgesias,  and  hyperesthesias. 

Neuritis. — Actual  neuritis  is  not  as  commonly  seen  as  with  other  occu- 
pational poisons,  such  as  from  lead,  mercury,  and  arsenic.  Nevertheless, 
we  find  neuritis  reported  in  the  literature.  Lancereaux  mentions  a  paralysis 
of  the  leg  due  to  a  carbon  monoxide  neuritis.  Krantz^^  refers  to  a  poly- 
neuritis following  gas  poisoning. 

Other  nervous  complications  to  be  enumerated  are  deafness,  amblyopia, 
and  diplopia.  The  English  Factory  Inspector  reports  a  case  of  diplopia 
lasting  2  2  days  following  a  carbon  monoxide  "gassing." 

Gangrene. — The  writer  has  never  personally  seen  this  complication,  but 
refers  to  those  reported  by  Alberti'^"  and  McLean.^"-  In  the  former's  case 
there  appeared  soon  after  "gassing"  blebs  containing  a  brownish  fluid 
material,  showing  a  carbon  monoxide  spectroscopic  picture.  Later  extensive 
gangrene  of  the  elbow,  lower  limbs  and  the  neck,  with  a  lethal  termination, 
developed.  In  McLean's  case  there  were  scattered  areas  of  gangrene  in  the 
legs.  The  pathological  basis  of  gangrene  with  carbon  monoxide  poisoning 
is  uncertain,  some  considering  it  due  to  thrombosis,  others  to  trophic  and 
degenerative  changes  in  the  tissue  itself. 

TREATMENT  OF  GAS  POISONING 

Prophylaxis. — In  this  chapter  the  writer  will  deal  only  with  the  preven- 
tion of  acute  industrial  "gassing." 

The  prevention  of  industrial  "gassing"  is  dependent  on  (i)  the  employer, 
(2)  the  employee,  and  (3)  the  state. 

The  employer  is  responsible  for  the  placing  and  operating  of  gas-producing 
machinery,  and  the  administration  of  safety  rules  for  his  employees. 

The  large  steel  companies  have  been  on  the  alert  to  adopt  every  modern 
appliance  with  a  tendency  of  preventing  gas  poisoning.  The  Illinois  Steel 
Company's  safety  department,  composed  of  both  employers  and  employees, 
continually  considers  the  methods  and  means  of  preventing  "gassing." 
The  following  methods  have  decreased  gas  poisoning  in  steel  mills  to  a  mini- 
mum in  the  opinion  of  the  writer.  First,  the  adoption  of  automatic  top-filling 
furnaces  (see  pictures  comparing  old  and  new  style  furnaces);  second,  the 
use  of  overhead  mains  instead  of  underground;  third,  reduction  of  leakage  by 
improved  methods  of  lining  and  riveting  the  furnace  and  pipe  walls;  fourth, 
by  enforcing  adequate  safety  rules. 

The  illuminating  gas  companies  and  large  producer  gas  users  must  also  be 
commended  in  Illinois  for  improved  methods  of  prevention. 

The  employee  also  shares  responsibility  in  his  work  of  prevention.  He 
must  learn  to  recognize  the  danger  of  gas  and  its  sources.  Of  dangerous 
occupations  it  might  be  said  that  familiarity  breeds  contempt.     Reference 


CARBON   MONOXIDE    POISONING  67 

is  here  made  to  the  switchman,  who,  in  spite  of  persistent  warnings,  will 
jump  the  cowcatcher  of  the  engine  while  in  motion.  Alcohol  should  be 
abstained  from  during  or  before  working  hours.  Some  men  have  gone  to 
sleep  under  the  influence  of  alcohol  alongside  the  comfortable  warmth  of  a 
furnace  to  be  found  by  his  fellow-workers  fatally  "gassed." 

The  state  is  advancing  in  factory  regulation.  Nearly  all  civilized  govern- 
ments have  adopted  laws  for  the  prevention  of  industrial  accidents  and 
diseases.  The  state  of  IlHnois  does  not  control  gas  poisoning  by  its  Occu- 
pational Disease  Law,  which  provides  more  specifically  for  disease  from  lead, 
brass,  zinc,  arsenic,  and  phosphorus,  but  regulates  the  danger  from  gas 
poisoning  by  means  of  the  Health  Safety  and  Comfort  Law,  which  provides 
for  safe  machinery,  necessary  ventilation  and  the  safe  removal  of  obnoxious 
and  poisonous  dusts  and  gases. 

The  following  laws  are  enforced  by  British  Factory  Inspectors: 

1.  Notices  are  exhibited  at  different  parts  of  the  works  calling  attention 
to  the  dangers  of  the  gas. 

2.  Men  engaged  in  flue  cleaning  are  never  permitted  to  work  single  handed 
nor  are  both  men  permitted  to  enter  the  tube  at  the  same  time.  They  can 
watch  their  mate  by  turn. 

3.  No  workman  is  allowed  to  enter  the  tube  until  it  is  cleared  of  gas. 
External  work,  such  as  raking  out  the  dust  from  the  bottom  doors,  is  always 
completed  first. 

4.  During  cleaning,  a  cylinder  of  compressed  oxygen,  connected  to  a  pul- 
motor,  is  kept  on  the  spot.  Various  persons  have  been  instructed  in  the  use 
of  the  pulmotor,  which  is  a  mechanical  device  for  causing  artificial  respiration 
at  the  same  time  supplying  a  60  per  cent,  mixture  of  oxygen  and  air. 

5.  Attendants  are  supplied  with  ropes  for  rescue  purposes,  and  a  smoke 
helmet  with  bellows  and  piping,  which  the  attendants  would  use  in  order  to 
enter  the  tube  to  tie  on  the  rope  to  any  one  "gassed,"  and  assist  him  out  of  the 
tube. 

Following  are  regulations  adopted  by  the  Illinois  Steel  Company  per- 
taining to  "gassing:" 

1.  "Never  go  into  a  gas-engine  house  or  electric  motor  room  unless  your 
duties  take  you  there,  and  you  have  special  instructions  from  your  foreman. 

2.  ''Work  around  blast  furnaces  is  very  dangerous,  because  of  escaping 
gas,  the  possible  breaking  out  of  the  side  of  a  furnace,  explosions,  and  the 
blowing  of  hot  stock  out  of  the  top  of  the  furnace.  These  dangers  cannot 
always  be  guarded  against  by  those  in  charge,  and  every  one  near  a  furnace 
must  be  watchful  for  his  own  safety. 

3.  Gas  May  Kill  You. — Dangerous  gas  may  be  found  anywhere.  Some- 
times you  cannot  see  or  smell  it.  It  may  make  you  unconscious  before  you 
know  gas  is  present.  Sometimes  gas  makes  you  feel  dizzy,  or  gives  you  a 
headache,  or  stiff  neck  or  weak  legs.  When  you  feel  any  of  these  symp- 
toms, get  into  fresh  air. 


68  OCCUPATIONAL   INTOXICATIONS 

4.  ''Employees  are  forbidden  to  go  top  of  a  furnace  without  the  per- 
mission of  the  General  Furnace  Foreman. 

5.  "Before  working  around  the  explosion  doors,  bell  rods  or  hangers,  or 
doing  any  work  between  the  big  bell  and  gas  seal,  see  that  the  gas  valves  are 
closed,  that  the  gas  escaping  from  the  stock  is  lighted  and  that  the  man 
operating  the  bells  is  notified. 

6.  "Before  changing  tuyeres,  notice  should  be  given  the  party  in  charge 
of  filling  the  furnace  to  stop  filling  until  he  gets  notice  that  tuyeres  have  been 
changed.  This  is  to  prevent  gas  from  blowing  out  on  the  men  through  the 
tuyere  openings  of  the  furnace. 

7.  "  Keep  away  from  valves  under  dust  catchers  and  down  legs,  especially 
when  a  furnace  slips.     There  is  danger  from  gas. 

8.  "You  must  not  go  anywhere  above  the  floor,  around  a  blast  furnace 
(around  bustle  pipes,  water  troughs,  valves,  roofs,  stoves,  etc.),  without 
first  telling  the  General  Foreman  on  the  Blower  of  that  furnace. 

9.  "Stove  Cleaner  Foreman  must  order  men  out  of  stoves  when  the  wind 
is  off  the  furnace  or  when  a  furnace  is  slipping  badly,  as  there  is  danger  of 
gas  from  the  Furnace  backing  into  the  stoves  and  igniting. 

10.  "Keep  out  of  the  engine  rooms  unless  your  duties  take  you  there. 
There  is  great  danger  from  gas. 

11.  "Never  work  in  the  basement  alone — always  have  a  helper  with  you. 
Gas  may  kill  you. 

12.  "If  you  find  a  man  'gassed,'  get  him  into  the  open  air  and  call  fore- 
man at  once. 

13.  "  Gas  may  be  found  anywhere;  never  go  into  holes  or  out  of  the  way 
places  alone." 

Resuscitation. — The  above-mentioned  regulations  show  clearly  how  the 
workman  is  removed  from  a  gas  atmosphere  without  "gassing"  more  men. 
Resuscitation  is  then  begun.  This  is  usually  conducted  at  the  site  of  the 
"gassing"  up  to  the  point  where  the  patient  can  be  safely  removed  to  a  hos- 
pital or  his  home.  Many  industrial  "gassings"  do  not  demand  much  more 
treatment  than  removal  to  pure  air.  Not  all  are  deep  comas;  in  fact  the 
majority  are  mild  in  which  the  patient  is  only  in  a  simple  stupor. 

Artificial  respiration  should  be  begun  as  soon  as  possible,  either  by  attend- 
ants or  by  means  of  a  pulmotor.  Tanks  of  oxygen  and  pulmotors  are  kept 
close  to  the  furnaces  in  many  companies.  Experimental  work  performed  by 
Haldane  shows  that  an  atmosphere  of  oxygen  keeps  the  patient  alive  much 
longer  than  an  atmosphere  of  air.  The  writer  does  not  deem  it  necessary  to 
go  into  detail  as  to  the  relative  merits  of  using  oxygen  in  pure  state  or  the 
pulmotor  with  a  mixture  of  nitrogen  and  oxygen.  Either  may  be  used 
for  resuscitation,  but  great  care  should  be  employed. 

The  patient  should  be  wrapped  in  blankets  or  be  removed  to  a  dry,  warm 
place. 

After  removal  to  a  hospital  the  writer  recommends,  if  the  pulse  is  strong 


CARBON   MONOXIDE   POISONING  69 

and  the  blood  pressure  not  subnormal,  a  venesection  of  500  cc.  of  blood  with 
the  simultaneous  administration  of  normal  salt  solution  by  hypodermoclysis. 

Stimulants  such  as  caffeine,  strychnine,  and  camphorated  oil  are  also 
useful.  Catharsis  and  sedatives  are  of  use  for  the  distress  which  for  a 
few  days  follows  a  gas  intoxication. 

SequellcB. — Time  does  not  permit  a  discussion  of  the  treatment  of  the 
sequellae.  Moreover  they  come  properly  under  the  direction  of  the  internist, 
surgeon,  and  psychiatrist. 

CHRONIC  CARBON  MONOXIDE  POISONING 

Sommerfeld^-  states  that  chronic  carbon  monoxide  poisoning  produces 
headaches,  vertigo,  nausea,  vomiting,  coated  tongue,  amnesia,  anaemia, 
flushes,  formication,  heart  palpitation,  nervousness,  and  malaise.  It  is 
true  that  many  persons  who  are  continually  subjected  to  small  continuous 
doses  of  the  gas  are  sometimes  afflicted  with  the  symptoms  mentioned  above. 
The  writer  has  personally  seen  undisputed  cases  of  chronic  monoxide  intoxi- 
cation, confirming  such  by  means  of  a  method  which  will  be  mentioned  later. 
Nevertheless,  upon  critical  examination  of  240  men,  in  1910,  together  with 
Dr.  Matthew  Karasek,  and  upon  further  investigation  since  then,  the  writer 
must  conclude  that  a  worker  can  acclimate  himself  to  CO  within  certain 
limits.     An  explanation  will  be  offered  for  this  in  a  subsequent  chapter. 

Carbon  monoxide  is  found  in  small  quantities  in  the  steel  companies 
about  the  blast  furnaces,  about  producer  furnaces,  illuminating  gas  plants, 
about  the  street  gas  mains,  in  motor  garages,  in  rooms  where  electrotyping, 
stereotv'ping  and  monot}^ing  is  done,  in  foundries,  above  the  machine 
solderers,  in  can  making,  in  smelters  of  ores,  in  rooms  where  salamanders  are 
being  used,  in  laundries  and  bakeries,  and  in  tailor  shops  from  the  ironing 
goose. 

In  making  quantitative  analyses  on  air  collected  in  such  establishments  as 
are  mentioned  in  the  previous  paragraph,  the  writer  has  found  a  great  varia- 
tion in  the  CO  present,  at  different  times  and  in  different  parts  of  the  same 
room.  Analyses  have  been  made  in  motor  garages,  above  the  soldering  kettle 
of  a  linotype  machine,  and  in  tailor  shops  while  the  goose  was  being  used, 
in  collaboration  with  J,  N.  Schumacher. 

In  five  analyses  made  in  motor  garages  the  CO  content  of  the  air  was  as 
follows: 

Per  cent. 

1.  CO 0.02 

2 .  CO 0.13 

3.  CO o .  04 

4.  CO o .  CO 

5.  CO 0.02 

The  average  for  above  five  samples  was  0.042  per  cent.  CO. 

We  recommend  the  following  method  for  obtaining  qualitative  and  quan- 
titative analyses  of  CO  in  suspected  rooms. 


yo  OCCUPATIONAL   INTOXICATIONS 

A  glass  sampler,  such  as  is  ordinarily  used  for  collecting  gases,  is  com- 
pletely filled  with  water,  and  simply  allowed  to  drain  in  the  atmosphere  of 
which  a  sample  is  desired.  The  exit  of  water  causes  the  entrance  of  the  de- 
sired air  or  gas.  The  sample  is  now  ready  for  analyses,  having  only  to  be 
displaced  into  any  apparatus,  which  may  be  selected  for  analysis,  depending 
on  the  analytical  process  selected.  Using  the  pentoxide  of  iodine  method, 
for  instance,  the  gas  is  caused  to  pass  through  a  tube  containing  KOH, 
which  removes  CO2,  then  through  H2SO4,  which  in  turn  eliminates  any  alkali 
and  moisture.  From  here  the  gas  passes  through  the  pentoxide  of  iodine 
which  is  contained  in  a  tube  surrounded  by  a  heated  oil  bath,  3oo°F.  It  is 
here  that  the  carbon  monoxide  reacts  with  the  pentoxide  of  iodine  so  as  to  set 
free  iodine,  which  is  then  absorbed  in  a  solution  of  KI  (0.5  gram  to  10  cc.  of 
water)  and  subsequently  estimated  quantitatively  by  titration. 

The  qualitative  determination  simply  demands  a  starch  solution  into 
which  the  CO  liberates  the  iodine,  turning  the  starch  solution  blue. 

The  method*  of  titrating  the  KI  containing  the  I  liberated  by  CO  is  to 
titrate  this  solution  against  thio-sulphate  N/iooo. 

Pathology. — The  pathology  of  chronic  carbon  monoxide  poisoning  does 
not  refer  to  post-mortem  findings,  since  there  exists  no  cause  of  death  from 
chronic  intoxications,  but  to  the  clinico-pathological  examination  of  the 
blood. 

During  the  Illinois  investigation  of  1910,  a  critical  examination  was  made 
of  240  men  who  had  either  recently  been  "gassed"  or  who  had  been  subject 
to  frequent  "gassings."  During  this  work  the  blood  of  68  men  was  examined 
by  Dr.  Matthew  Karasek  and  the  writer,  with  the  following  observations: 

1.  That  there  existed  a  polycythemia  in  these  cases  of  5,500,000  to 
9,676,000,  66  per  cent,  being  over  6,000,000  cells  per  cu.  mm. 

2.  No  cell  such  as  poikilocytes,  normoblasts,  microblasts,  etc.  No 
embryonal  red  cells. 

3.  Hemoglobin  estimated  from  95  per  cent,  to  125  per  cent.,  more  estima- 
tions being  over  100  per  cent,  than  under.     Whites  7000  to  10,000. 

Color  index  under  five-sevenths. 

6.  Eosinophiles  in  about  two-sevenths  cases  from  5.5  per  cent,  to  8.5 
per  cent.,  myelocytes  in  one-third  cases  as  high  as  3  per  cent.  Basophiles 
rare. 

Similar  work  was  done  by  Drs.  Nasmith  and  Graham^^  on  guinea-pigs. 
They  allowed  the  animals  a  saturation  of  25  per  cent,  of  the  coloring  matter 
of  the  blood,  with  carbon  monoxide.  The  guinea-pigs  inhaled  this  gas  daily 
for  several  weeks.  Although  their  blood  was  saturated  with  25  per  cent. 
CO,  they  did  not  loose  weight,  become  anaemic,  nor  show  any  signs  of  dis- 
turbance from  the  gas. 

Following  is  quoted  from  the  work  of  Drs.  Nasmith  and  Graham: 

"With  25  per  cent,  of  its   blood  rendered  useless  for  oxygen-carrying 

*  aNaSjOs  -f  2I  =  aNal  +  Na2S406. 


CARBON   MONOXIDE   POISONING 


71 


purposes,  by  its  union  with  CO,  the  guinea-pig  is  capable  of  compensating 
and  will  manufacture  new  red  blood  corpuscles  until  it  has  reached  a  total 
of  8,000,000  with  a  corresponding  hemoglobin  content  of  105  per  cent.  The 
normal  number  of  erythrocytes  in  the  peripheral  circulation  of  guinea-pigs 
is  about  6,000,000  with  88  per  cent,  hemoglobin.  The  animal  with  true 
compensation  has  three-fourths  of  8,000,000  or  6,000,000  erythrocytes  and 
three-fourths  of  105  per  cent,  or  79  per  cent,  hemoglobin  still  available. 
Thus  there  is  only  a  total  loss  for  oxygen-carrying  purposes  of  9  per  cent, 
of  its  hemoglobin." 

Following  were  their  conclusions  of  their  entire  experiment  with  CO: 

1.  "CO  acts  as  a  poison  solely  by  its  ability  to  prevent  the  normal  supply 
of  oxygen  from  reaching  the  tissues,  and  thereby  deranging  the  normal 
metabolism  of  the  body  cells. 

2.  "Guinea-pigs  living  continuously  in  a  dilute  atmosphere  of  carbon 
monoxide,  so  that  the  oxygen-carrying  power  of  the  blood  is  reduced,  are  able 
by  increasing  the  quantity  of  hemoglobin  and  number  of  erythrocytes  to 
compensate  for  this  loss  and  maintain  an  oxygen-carrying  capacity  approxi- 
mately equivalent  to  that  of  the  original  blood. 

3.  "CO  poisoning  is  followed  by  a  leucocytosis  of  the  eosinophile  and 
pseudo-eosinophile  forms.  A  moderate  saturation  produces  a  moderate 
toxaemia  involving  an  eosinophilia  like  nearly  all  moderate  toxaemias.  A 
high  saturation  causes  a  severe  toxaemia  in  the  course  of  which  the  eosino- 
philes  disappear,  as  in  all  severe  toxaemias.  A  high  prolonged  saturtation 
brings  about  the  appearance  of  erythroblasts  and  myelocytes,  indicating 
hyperactivity  on  the  part  of  the  parent  cells  in  the  bone  marrow. 

4.  "The  effect  of  CO  in  increasing  the  number  of  the  erythrocytes  in 
the  blood  is,  in  many  respects,  similar  to  those  of  high  altitudes,  in  the  pe- 
ripheral circulation  at  least." 

The  writer  at  this  point  presents  a  partial  representation  of  work  done  on 
acute  and  chronic  "gassing"  in  the  period  from  1910  to  1914. 

Table  I 


Case 


Duration 
of  coma 


Red 
count 


Red  count    Red  count 
third  day     sixth  day  i 


HB  (Dare) 


White 
count 


Female,    illuminating  ■  ■  %       %    '    % 

gas 10  hours  4,876,240  5,200,400  4,906,430     80       90      90     19,460 

Male,  42  years,  illumi- 
nating gas 23  hours  5,267,000   5,640,300  5,602,100     90      100    100     18,760 

Male,  47  years,  illumi-  : 

nating  gas 3  hours  5,100,800   5,706,060  5,980,760     95        95;    95  |  16,600 

Male,  31  years,  blast- 
furnace gas 6  hours  4,878,410   5,146,700  5,317,000     95      100     100     12,860 

Male,  39  years,  illumi- 
nating gas 27  hours  5,163.700  6.821,300  6,251,100     95      100     100       0,791 


72 


OCCUPATIONAL   INTOXICATIONS 
Table  II 


Sex 


Occupation 


How  long 
employed 


Red  blood 
count 


Symptoms  noted 


Female Tailor  shop 

Female Laundry 

Male Can  manufacturer 

Male. Can  manufacturer 

Male Can  manufacturer 

Male Salamander 

Male Salamander 

Male Salamander 

Male Salamander 

Male Tailor 

Male ,  Tailor 


6  years 

I  year 

2  2  years 

lo  years 

4  years 
3  years 

5  years 
5  years 

12  years 

5  years 

6  years 


5,762,100 
6,432,130 
7,6ii,3jo 
16,421,140 
[5,280,710 
8,497,600 
6,311,000 
6,131,000 
4,376,000 
6,378,000 
5,810,000 


Headaches 

Headaches 

Headache,  anorexia 

Neurasthenia 

Neurasthenia 

Headaches,  anorexia 

Nausea 

Headaches 

Headaches 

Headaches 

Headaches 


The  above-mentioned  work  gives  reason  for  saying  that  the  blood-forming 
organs,  tending  to  compensate  a  loss  of  oxygen-carrying  power  in  many 
individuals,  cause  an  increase  in  the  number  of  red  cells  and  the  quantity  of 
the  hemoglobin. 

Symptomatology. — Since  acute  "gassing"  may  occur  in  so  mild  a  manner 
so  as  to  produce  only  a  headache,  it  is  easy  to  confuse  acute  and  chronic 
carbon  monoxide  poisoning.  When  mention  is  made  of  certain  symptoms 
as  being  so-called  chronic  carbon  monoxide  poisoning,  we  must  eliminate 
the  possibility  of  error  by  investigating  whether  any  certain  patient  presents 
such  symptoms  continually  or  at  regular  periods,  and  it  is  also  well  to  under- 
stand that  such  a  person  is  continuously  exposed  to  small  quantities  of 
this  gas,  or  is  "gassed"  frequently  in  a  very  mild  manner. 

Persons  who  will  not  acquire  a  tolerance  to  the  gas  will  become  anaemic, 
irritable,  neurasthenic,  and  complain  of  headaches,  anorexia,  loss  of  weight, 
backaches,  vertigo  and  gastro-intestinal  disorders. 

Whether  the  compensating  power  of  the  blood-forming  organs  in  those 
persons  living  with  a  polycythemia  will  ever  exhaust  itself,  as  in  the  case 
of  a  hypertrophied  leaky  heart,  is  yet  to  be  determined.  The  writer  has  not 
been  able  to  find  a  greater  incidence  of  pernicious  anaemia  among  blast-furnace 
workers. 

The  diagnosis  of  chronic  carbon  monoxide  poisoning  was  recently  made 
by  the  writer  in  the  following  manner.  A  person  engaged  as  a  mechanician 
in  a  can-making  concern  was  referred  to  the  writer  by  Dr.  William  E.  Evans, 
of  Chicago,  to  determine  the  occupational  element  in  the  man's  disorder. 
It  was  necessary  in  the  patient's  work  to  occupy  himself  for  certain  periods 
every  day  over  a  burning  machine  solderer,  during  which  time  it  was  possible 
to  inhale  carbon  monoxide  fumes.  The  patient  complained  of  a  symptom- 
complex  very  much  like  that  usually  mentioned  under  chronic  CO  poisoning. 
Upon  excluding  tuberculosis,  as  far  as  my  ability  permitted  me,  nephritis, 
and  especially  lead  poisoning,  the  latter  by  means  of  a  blood  examination 


CARBON   MONOXIDE    POISONING  73 

for  stippling  and  a  urine  analysis  for  lead,  a  red  count  was  obtained  in  the 
neighborhood  of  7,000,000  red  cells.  The  diagnosis  of  chronic  carbon  mon- 
oxide was  made.  Upon  changing  his  manner  of  work  the  patient  obtained 
relief. 

A  loss  of  muscular  power  seems  to  occur  in  those  subjected  to  carbon 
monoxide  poisoning.  This  should  be  referred  to  as  a  sign  of  chronic  intoxica- 
tion. Dr.  Matthew  Karasek  and  the  writer  made  comparative  tests  on  the 
workmen  about  a  blast  furnace,  and  on  those  working  in  non-gas  productive 
industries,  selecting  as  much  as  possible  workers  of  the  same  nationality  and 
habits.  Diminution  in  strength,  as  noted  by  the  hand  dynometer,  was 
noted  in  those  subject  to  the  gas. 

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74  OCCUPATIONAL   INTOXICATIONS 

21  McLean. — "Carbon  Monoxide  Poisoning  with  Gangrene  in  Both  Legs."     J.  Am.  Med. 

Ass.,   Chicago,  191 1,  LVI,  1455-57. 
"  Sommerfeld,  Theo. — "Entwurf  einer  Liste  der  gewerblichen  Gifte  im  Auftrage  der  Inter- 

nationalen  Vereinigung  f iir  Gesetzlichen  Arbeiterschutz  unter  Mitwirkung  von  Prof. 

Thos.  Oliver,  und  Dr.  Putzeys."  Jena,  1908. 
^^  W.  Gilman  Thompson. — "Occupational  Diseases." 
2^  Quensel. — "Psychoses  durch  Kohlenoxyd  Vergiftung."     Med.  Klin.  Berl.,  191 2,  VIII, 

434-437-  _^ 
^^  S.  Delepine. — "The  Pathogenic  Properties  of  the  Gas  Discharged  by  the  Exhaust  Pipe  of 

Gas  Engines."     Public  Health,  May,  1911. 
2^  Munroe. — "Physiological  Effects  of  Carbon  Monoxide."     School  of  Mines,  Quart,  N.  Y., 

1912. 
^''  Hartridge. — "A  Spectroscopic  Method  of  Estimating  Carbon  Monoxide."     J.  Physiol., 

Lond.,  191 2,  1913,  XLIV. 
**  Becker. — "Ueber  Nachkrankheiten  der  Kohlenoxyd  Vergiftung."     Deutsche  Med.  Woch- 

enschr.,  15,  1889,  page  513. 
^'Rogues,  J. — "LTntoxication  Oxycarbonic  chronique."     Arch.  d'Anthrop.  Crim.  Lyonet 

Par.,  1913,  XXVIII,  495-501. 
^°  Theo.  Weyl. — "Handbuch  der  Arbeiter  Krankheiten." 
^1  The  Reports  of  the  English  Inspector  of  Factories  and  Workshops,  1905- 1913. 

22  Nasmith  and  Graham. — "Hematology  of  Carbon  Monoxide  Poisoning."     Journ.  Physiol. 

Lond.,  1906-1907,  XXXV,  32. 
''  Kolisko. — "Die  symetrischeEncephalomalacieindenLinsenkernen  nach  Kohlenoxydgas- 

vergiftung."     Beitrage  zur  gerichtlichen  Medicin,  2,  1914,  pages  1-16. 
**  Fischbein,  Morris. — "illuminating  Gas  Poisoning."     Journ.  Am.  Med.  Ass.,  Chicago,  Vol. 

LX,  pages  737-738. 


SECTION  V 
LEAD  POISONING 

BY  SIR  THOMAS  OLIVER,  M.  D.,  Xewcastle-upon-Tyne,  England. 

Although  lead  poisoning  has  existed  from  time  immemorial,  we  yet  learn 
little  or  nothing  of  it  from  Eg}^tian  history.  When  Rome  was  at  the  height 
of  her  power  and  the  supply  of  water  for  drinking  purposes  and  for  baths 
became  a  pressing  requirement,  also  when  the  question  had  been  partly 
solved  by  the  large  aqueducts  built  by  her  engineers,  the  use  of  lead  pipes 
for  domestic  distribution  became  more  or  less  a  necessity.  That*  thft  people 
suffered  from  drinking  lead  contaminate^  water  is  evident  from  the  condem- 
nation of  the  metal  by  Vitrivius,  thg,Roman  architect.  In  one  of  the  large 
Roman  Camps  near  Newcastle-iipon-Tyne  I  found  lead  pipes  which  had  been 
used  for  the  conveyance  of  water  through  the  Camp.  The  Romans  in  mak- 
ing lead  pipes  did  not  mould  the  pipe  as  is  done  to-day,  they  simply  beat 
flattened  lead  into  a  tubular  shape. 

In  medical  literature  lead  poisoning  occurs  under  various  names,  e.g., 
saturnism,  phtmbism,  colica  pictonum  and  colica  pidorum.  The  sources 
of  the  poisoning  are  industrial  and  accidental.  Occasionally  lead  poisoning 
has  assumed  epidemic  proportions:  it  has  broken  out  in  a  town  owing  to  the 
drinking  water  possessing  strong  plumbo  solvent  properties.  The  "gathering 
ground"  has  much  to  do  with  the  plumbo  solvency.  A  peaty  soil  is  apt  to 
render  water  slightly  acid,  owing  to  humic  and  ulmic  acids,  and  to  confer 
upon  it  plumbo  solvent  properties.  Rainy  weather  succeeding  a  long  drought 
also  favors  the  disposition  of  the  water  to  attack  lead.  The  presence  of 
certain  microorganisms  in  peaty  water  is  not  without  considerable  influence. 
Houston  found  two  non-motile,  non-liquefying  bacteria  in  peat;  these 
possessed  separately  the  properties  of  acidity  and  plumbo  solvency.  Dis- 
tilled water  attacks  fresh  lead  pipes  with  considerable  vehemence.  The 
presence  of  oxygen  in  the  water  favors  the  action;  so  too  does  carbon 
dioxide.  On  the  other  hand,  the  presence  of  calcium  carbonate  confers  a 
protective  influence  so  long  as  the  water  remains  free  from  acid.  Nitrates 
and  chlorides  in  water  tend  to  corrode  lead.  Silicates  possess  protective 
properties.  The  plumbo  solvency  of  drinking  water  can  be  considerably 
reduced  and  the  water  rendered  safe  for  personal  and  domestic  purposes 
by  the  addition  of  fragments  of  limestone,  magnesium  limestone  and  chalk, 
to  the  filtering  beds,  but  care  must  be  taken  even  with  those,  since  the 
addition  of  too  large  a  quantity  of  chalk,  for  example,  may  be  followed  by 
results,  the  direct  opposite  to  those  which  were  expected.  There  is  a  limit  in 
regard  to  the  power  for  good  of  these  alkaline  earths  which  can  only  become 

75 


76  OCCUPATIONAL    INTOXICATIONS 

known  by  testing  the  plumbo  solvency  of  the  water  two  or  three  times'a  year. 
There  is  a  difference  too  in  the  effect  due  to  the  age  of  the  lead  pipe.  New 
lead  pipes  are  more  susceptible  to  the  influence  of  water  than  those  which  are 
old.  J.  F.  Liversuge  and  A.  W.  Knapp,^  as  the  result  of  a  series  of  experi- 
ments found  that  when  a  new  pipe  containing  water  was  closed  for  17  hours 
about  half  the  lead  removed  was  dissolved  in  the  first  4  hours  and  that 
the  average  amount  of  lead  dissolved  from  pipes  increased  with  time  up  to 
44  weeks.  After  a  year  the  age  of  the  pipes  gains  little  or  no  further  pro- 
tection. Different  parts  of  a  lead  pipe  yield  different  amounts  of  lead  to 
water  under  similar  conditions.  This  circumstance  and  that  of  temperature 
are  partly  responsible  for  the  fact  that  the  water  removed  from  a  tap  in  a 
certain  part  of  a  town  may  possess  different  plumbo  solvent  powers  to  that 
drawn  in  another  part  of  the  town.  It  was  found  that  the  lead  pipes  made 
in  Paris  responded  less  to  the  influence  of  water  than  those  brought  from 
Nantes.  Water  drawn  from  one  of  the  large  hospitals  in  Paris  was  found 
to  contain  55  mg.  of  lead  per  liter,  whereas  water  drawn  in  a  house  in  a 
different  part  of  this  city,  but  at  the  same  time  of  day,  contained  only  1.6 
mg.  of  the  metal.  The  presence  of  metals  other  than  lead  in  the  pipe  in- 
duces electrolytic  action  which  causes  dissolution  of  lead.  Where  pipes 
containing  lead,  antimony  and  tin  have  been  substituted  for  ordinary  lead 
pipes  the  results  have  been  disastrous. 

It  is  impossible  to  say  definitely  what  amount  of  lead  in  drinking  water  is 
dangerous.  Much  depends  upon  the  amount  of  water  drunk  by  the  indi- 
vidual. Water  containing  i  to  2  mg.  of  lead  per  liter  might  have  little  in- 
fluence upon  a  person  who  consumed  1000  cc.  in  24  hours  but  the  results  would 
be  different  if  2  liters  or  more  were  drunk  daily.  Toxicologists  are  of  the 
opinion  that  water  which  contains  5  mg.  of  lead  per  liter  is  dangerous.  It 
is  the  daily  absorption  of  minute  quantities  of  lead  which  is  harmful  to  the 
organism.  Since  water  standing  in  the  pipes  over  night  may  have  dissolved 
a  considerable  quantity  of  lead,  the  tap  ought  to  be  turned  on  and  the  water 
allowed  to  run  every  morning  for  few  minutes  before  it  is  used  for  culinary 
purposes.  The  drinking  water  for  the  table  should  be  passed  through  a 
carbon  filter  rich  in  animal  phosphate. 

Another  accidental  source  of  lead  poisoning  is  food — especially  tinned 
food.  An  acid  fruit  such  as  pineapple  is  particularly  prone  to  attack  the 
lead  present  in  the  solder  of  the  tin.  One  of  my  worst  cases  of  lead  poison- 
ing was  that  of  a  lady  librarian.  She  suffered  severely  from  colic  and  double 
wrist  drop  in  consequence  of  having  eaten  almost  daily  for  months  tinned 
salmon. 

Persons  addicted  to  the  habit  of  snuffing  occasionally  suffer.  One  of 
my  patients  was  in  the  habit  of  keeping  the  snuff  in  lead  foil.  Discovery  of 
the  cause  soon  led  to  disappearance  of  the  symptoms. 

Industrial  lead  poisoning  is  extremely  prevalent.  It  is  not  always 
diagnosed.     Lead  is  used  in  some  form  or  other  in  upward  of  no  industries. 


LE.AD   POISONING  77 

Although  lead  mining  is  an  old  British  industry  it  is  not  a  cause  of  plumbism 
owing  to  the  fact  that  the  metal  in  the  ore  is  in  the  form  of  sulphide  and 
therefore  extremely  insoluble.  In  this  form  the  ore  is  known  as  galena. 
Where  the  ore  occurred  as  cerussite,  in  other  words  as  an  almost  pure  car- 
bonate, miners  have  suffered  severely  in  health.  This  occurred  two  to  three 
decades  ago  at  the  Broken  Hill  IMines  in  Australia.  Since  the  cerussite  at 
Broken  Hill  has  all  been  worked  out  and  nothing  remains  but  galena  the 
occupation  of  the  miner  has  become  healthier. 

Smelting  of  Lead  Ore. — The  risk  of  plumbism  commences  with  the 
smelting  of  the  ore.  There  are  several  ways  of  smelting  lead  ore,  the  best 
known  being  the  open  hearth,  or  Scotch  system,  and  the  blast  furnace. 
During  smelting,  fumes  are  given  ofif  which  are  rich  in  lead.  In  windy 
weather  or  when  the  flues  are  not  drawing  well  there  may  be  a  down- 
draught  so  that  the  men  can  hardly  avoid  inhahng  some  of  the  fumes. 
Moreover,  in  the  Scotch  hearth  system  when  the  molten  lead  keeps  pour- 
ing into  the  receiver  or  when  the  slag  is  being  broken  up  the  workman 
runs  the  risk  of  inhaling  fumes  or  dust.  The  greatest  danger  the  smelter 
runs  is  in  cleaning  out  the  flues.  These  are  the  long  passages  which  carry 
away  from  the  hearth  or  the  blast  furnace  the  vapor  of  lead  combined  with 
the  carbon  and  ash  particles  given  off  by  the  coal  or  coke  with  which  the 
ore  is  smelted.  The  fumes  may.  contain  as  much  as  60  per  cent,  of  lead  or 
more  in  the  form  of  oxide  and  sulphate.  The  flues  converge  toward  a  high 
chimney  situated  frequently  a  mile  away  from  the  smelting  works.  The 
object  of  the  length  of  the  flue  is  to  allow  the  fume  as  it  travels  to  become 
deposited,  with  the  view  of  recovering  the  lead  contained  in  it.  The  flues 
may  be  underground  passages  built  of  brick  or  wood  and  be  4  to  6  ft.  high 
so  that  a  man  can  stand  upright  in  them,  or  they  may  be  underground  gal- 
leries built  of  stone  or  brick  with  doors  here  and  there  so  that  men  can 
enter  the  flues  to  recover  the  lead  deposited.  Formerly,  more  than  in 
recent  years,  the  fumes  which  escaped  from  the  chimney  stalk  being  rich  in 
lead  not  only  spoiled  vegetation  in  the  immediate  neighborhood  of  lead  smelt- 
ing works  but,  becoming  deposited  on  pasture  land  upon  which  cattle  were 
grazing,  caused  the  death  of  these  animals  and  led  to  frequent  htigation  be- 
tween farmers  and  owners  of  smelting  works.  It  is  well  known  that  wild 
birds  are  occasionally  found  dead  in  the  vicinity  of  such  works.  The  district 
around  Linares  in  Spain,  an  important  center  of  the  lead  industry,  has  become 
extremely  barren.  The  goats  on  the  hillsides  have  suffered  considerably; 
when  pregnant  they  drop  their  young  before  term.  In  consequence  of  this 
immaternity  there  is  a  difficulty  of  rearing  goats  unless  they  are  removed 
to  another  locality. 

Cleaning  out  the  flues  is  a  dangerous  occupation.  Men  enter  them  and 
remove  the  deposit,  but  it  is  a  dusty  occupation  and  even  though  the  men 
when  thus  employed  wear  respirators,  the  fine  dust  passes  through  the  res- 
pirator and  makes  the  men  ill.     It  is  dangerous  work.     The  men  should  not 


78  OCCUPATIONAL   INTOXICATIONS 

be  allawed  to  work  in  a  flue  for  more  than  2  hours  at  a  stretch;  they  should 
then  be  off  for  4  hours.  The  work  causes  severe  headache,  creates  a  disinclina- 
tion for  food,  induces  retching  and  sometimes  vomiting.  If  the  headache 
commences  when  the  men  are  at  work  it  continues  all  day.  It  is  followed  by 
a  sleepless  night  and  frequently  also  by  a  rise  of  temperature.  Where  the 
flues  are  on  the  slope  and  water  can  be  added  to  flush  them  into  large  reser- 
voirs wherein  the  deposit  can  be  silted  there  is  less  risk  of  the  men  becoming 
ill.  A  good  illustration  of  this  occurred  recently  at  a  large  lead  works  in 
Newcastle-upon-Tyne.  Last  year  three  of  the  men  after  cleaning  out  flues 
were  ill  and  were  obHged  to  be  off  work  for  several  days.  It  was  summer 
weather.  After  the  men  had  opened  the  man-holes  of  the  flues  and  had 
worked  therein  for  a  few  hours  a  violent  thunderstorm  broke  over  the  city, 
accompanied  by  a  deluge  of  rain.  For  2  days  the  rain  fell  off  and  on.  In 
cleaning  out  the  flues  afterward  not  one  man  was  ill,  owing  to  the  large  quan- 
tity of  water  which  had  entered  the  open  man-holes.  It  had  soaked  through 
the  deposit  and  made  the  removal  of  it  attended  with  comparatively  little 
danger  to  the  men.  Employees  feel  that  they  must  recover  the  dust  from  the 
flues  for  it  may  contain  as  much  as  30  per  cent,  of  metallic  lead.  Tons  of 
deposit  are  removed  from  flues. 

De-silvering  of  Lead. — The  lead  removed  from  the  furnace  is  not  always 
pure  metal.  It  contains  silver  and  occasionally  antimony  and  gold.  These, 
from  a  white  lead  manufacturer's  point  of  view,  are  impurities  and  have 
to  be  removed.  Lead  crystallizes  at  a  higher  temperature  than  a  mixture 
of  lead  and  silver.  When  these  two  metals  are  present  together  in  the  melt- 
ing pot  a  crust  forms  on  the  surface  which  contains  much  silver  and  little 
lead.  This  is  skimmed  off  from  time  to  time  and  is  remelted.  On  each  oc- 
casion the  crust  becomes  richer  and  richer  in  silver.  Sometimes  zinc  is 
added  to  the  melting  pot  as  well.  The  crust  which  is  an  alloy  of  the  three 
metals  is  skimmed  off  and  the  zinc  extracted  in  a  de-zincing  furnace.  Men 
employed  as  de-silverers  suffer  from  plumbism.  The  smelting  of  zinc  is 
an  occasional  source  of  plumbism  owing  to  the  lead  frequently  contained 
in  zinc  ore.  Spelter,  although  seldom  containing  more  than  2  per  cent,  of 
lead,  is  a  frequent  source  of  plumbism  among  furnace  men.  During  53^^ 
years,  ending  December,  191 2,  77  spelter  workers  in  South  Wales  alone 
suffered  from  lead  poisoning.  Two  different  types  of  symptoms  are  met 
with  in  spelter  workers:  bronchitis  and  gastrointestinal  disorders,  which  are 
attributed  to  the  zinc  fumes,  also  nervous  affections  believed  to  be  due 
to  lead. 

Red  Lead. — Where  red  lead  is  made  in  the  open  hearth  by  raking  up  the 
molten  metal  and  allowing  air  to  become  intimately  mixed  with  it  the  resulting 
product,  known  as  massicot,  is  a  greenish  looking  substance  which  becomes 
yellow  or  yellowish  red  on  being  washed  with  water.  Washing  is  resorted  to  in 
order  to  remove  any  unoxidized  lead  which  may  be  present.  After  having  been 
thus  treated  the  massicot  is  replaced  in  the  furnace  and  kept  at  a  lower  tem- 


LEAD    POISONING  79 

perature  when  in  consequence  of  further  oxidation  its  color  changes  to  a 
bright  red.  It  is  then  known  as  minium  or  red  lead.  During  the  raking  of 
the  molten  metal,  fumes  escape  by  the  open  mouth  of  the  furnace  and,  al- 
though this  is  always  hooded,  some  of  the  fumes  may  be  inhaled  by  the  men. 
In  the  breaking  up  and  in  the  packing  of  red  lead,  dust  rises  very  freely. 
There  is  an  opinion  that  red  lead  is  not  dangerous.  Such  is  not  my  experi- 
ence. As  regards  harmfulness  there  is  little  to  choose  between  it  and  white 
lead.  In  this  opinion  I  am  supported  by  the  experience  of  Medical  Inspector 
E.  R.  Stitt-  of  the  United  States  Navy,  who  treated  three  seamen  who  were 
suffering  from  saturnine  encephalopathy  due  to  inhahng  red  lead  dust  rising 
from  dried  surfaces  during  the  act  of  chipping  off  of  old  paint  on  torpedo 
boats  preparatory^  to  their  being  repainted.  One  of  the  men  became  insane 
and  had  to  be  taken  to  an  asylum;  another  after  having  suffered  from  colic 
developed  convulsions.  All  the  men  recovered.  Red  lead  equally  with  the 
carbonate  is  capable  of  producing  the  most  severe  type  of  plumbism.  In  one- 
fourth  of  the  men  who  are  ill  in  consequence  of  ha\dng  been  exposed  to  red 
lead  the  symptoms  are  usually  severe.  The  making  of  red  lead  inclosed 
furnaces  and  conduits  will  do  much  to  diminish  the  number  of  cases  of 
plumbism  due  to  minium. 

White  Lead  or  Carbonate  of  Lead. — There  is  still  a  great  demand  for 
white  lead  despite  aU  that  has  been  said  and  written  against  it.  The  manu- 
facture of  white  lead  in  the  United  States  of  America  was  begun  in  1777. 
About  100,000  tons  are  produced  in  the  States  annually.  In  Great  Britain 
the  amount  produced  is  72,000  tons. 

The  two  principal  methods  of  manufacture  are  the  "Dutch"  and 
"Chamber"  processes.  In  the  Dutch  process  thin  perforated  plates  of  me- 
tallic lead  called  "grids  or  "^vickets""  are  placed  upon  the  open  mouth  of 
earthenware  jars  containing  a  quantity  of  weak  acetic  acid.  These  jars  are 
resting  on  a  layer  of  tan  bark  and  are  arranged  in  rows  in  a  large  quadrilateral 
space  one  side  of  which  is  open.  Upon  the  plates  of  metallic  lead,  planks  of 
wood  are  placed  and  upon  these  planks  fresh  tan  is  strewn  and  on  the  tan 
another  layer  of  earthenware  jars  is  deposited.  By  a  series  of  tiers  alternat- 
ing in  the  manner  described  the  "stack"  or  "blue  bed"  is  built  from  the 
bottom  upward.  When  each  tier  is  completed  planks  of  wood  are  placed 
across  the  open  space  leading  into  the  stack.  The  outer  doors  of  the  stack 
are  finally  closed  and  kept  closed  for  a  little  over  3  months.  Within  a  few 
days  of  closing  the  doors  the  temperature  inside  the  stack  rises.  This  may 
be  partly  owing  to  the  activity  and  reproduction  of  bacteria  within  the  tan 
or  it  may  be  due  to  chemical  change.  The  acetic  acid  volatilizes  and,  at- 
tacking the  lead  grids,  it  transforms  some  of  the  lead  into  acetate  of  lead. 
While  this  is  taking  place,  fermentation  occurs  in  the  tan  and  carbon  dioxide 
gas  is  generated.  This  reacts  upon  the  lead  acetate  whereby  it  is  converted 
into  hydroxycarbonate,  a  basic  compound  containing  two  molecules  of  normal 
carbonate  of  lead  in  combination  with  one  molecule  of  lead  hydrate  or  lead 


8o  OCCUPATIONAL   INTOXICATIONS 

oxide,  the  formula  being  2P6C03P6(OH)2.  After  having  been  closed  for  fully 
3  months,  and  when  it  is  believed  that  conversion  of  the  metallic  lead  into 
white  lead  has  become  complete,  the  doors  are  opened  and  men  enter  to  re- 
move the  "  corrosion  "  as  it  is  called.  The  process  is  known  as  "  stripping  the 
white  beds, "  and  as  there  may  be  .considerable  quantities  of  dust  raised  this 
particular  kind  of  work  is  denied  to  women. 

In  the  Chamber  process  strips  of  metallic  lead  resting  on  bars  are  exposed 
to  hot  acetic  acid  vapor,  also  to  carbon  dioxide  coming  from  burning  coke. 
The  doors  of  the  chamber  are  hermetically  closed  and  kept  shut  for  from  50 
to  60  days.  Before  the  workmen  enter  a  lead  chamber  to  empty  it,  steam 
must  be  injected  to  render  the  converted  white  lead  less  dusty  and  therefore 
less  dangerous.  The  doors  ought  to  be  opened  also  for  some  hours  before  the 
men  enter  in  order  to  reduce  the  temperature. 

Opinions  differ  as  to  the  relative  values  of  white  lead  manufactured  by 
the  Dutch  and  Chamber  processes.  The  latter  method  of  manufacture  is 
more  cleanly  and  the  time  required  for  the  corrosion  of  the  lead  is  shorter. 
House  painters  who  have  been  in  the  habit  of  using  white  lead  made  by  the 
Dutch  process  prefer  it.  The  fact  that  66  per  cent,  of  the  total  quantity  of 
white  lead  is  manufactured  by  the  Dutch  process  is  of  itself  its  strongest 
recommendation. 

Industrial  lead  poisoning  claims  fewer  victims  now  than  formerly.  Dur- 
ing 13  years,  1900  to  191 2  inclusive,  there  were  reported  to  the  Home  Office 
as  having  occurred  in  white  lead  factories  1393  cases  of  plumbism  with  ^t, 
deaths,  equal  to  2.2  per  cent.  If  the  total  number  of  cases  of  plumbism  noti- 
fied to  the  Home  Office  as  occurring  in  all  trades  be  taken,  there  were  during 
the  13  years  already  mentioned  8523  cases  with  394  deaths,  or  a  percentage  of 
fatal  cases  of  4.5.  During  recent  years  there  has  been  a  greater  reduction  of 
fatal  cases  of  plumbism  among  white  lead  workers  than  in  any  other  lead 
process,  largely  in  consequence  of  the  regulations  issued  and  enforced  by  the 
Home  Ofiice.  In  1900  the  largest  number  of  cases  of  plumbism  occurred  in 
the  white  lead  trade,  viz.,  358  with  six  deaths;  in  earthenware  and  pottery 
manufacture  200  cases  were  reported  with  eight  deaths.  In  191 2  the  manu- 
facture of  white  lead  no  longer  occupied  the  first  place  on  the  list.  This 
position  was  taken  by  the  earthenware  and  pottery  industry.  In  coach  and 
house  painting  the  number  of  cases  of  plumbism  has  risen  largely  owing  to 
the  prosperity  of  the  motor  car  industry.  House  painters  suffer  from  plumb- 
ism mostly  through  inhaling  dust  given  off  during  the  sand-papering  of 
flattened  surfaces  or  from  the  vapor  given  off  during  the  burning-off  of  old 
paint  preparatory  to  repainting.  In  the  case  of  persons  who  have  become 
ill  by  sleeping  in  newly  painted  rooms  opinions  have  somewhat  changed  as  to 
the  cause  of  their  indisposition.  Until  recently  it  was  thought  that  the  symp- 
toms were  those  of  plumbism,  and  where  a  blue  line  was  present  in  the  gums 
of  those  who  were  ill  the  diagnosis  was  probably  correct.  On  the  other  hand 
the  symptoms,  severe  headache,  nausea  and  retching,  developed  too  soon  after 


LEAD    POISONING  8 1 

exposure  to  paint  for  lead  to  be  their  cause.  The  symptoms  must  therefore 
be  due  to  the  inhalation  either  of  the  vapor  of  turpentine  alone  or  combined 
with  emanations  from  the  linseed-oil.  Baly  of  Liverpool  attributes  the  malaise 
to  the  inhalation  of  certain  aldehydes  given  oflf  by  lead  paints.  He  found  that 
lead  oxide  gave  off  more  "unsaturated  aldehyde"  than  lead  carbonate. 
Henry  A.  Gardner^  did  not  find  any  metal  present  in  the  vapors  given  off  by 
lead-painted  surfaces.  These  vapors  contain  varying  percentages  of  carbon 
monoxide  and  carbon  dioxide,  to  the  former  of  which  he  thinks  the  headache, 
vertigo  and  retching  may  be  ascribed.  Under  certain  conditions,  where 
traces  of  sulphuric  acid  are  present,  carbon  monoxide  is  given  off.  In  the 
blood  taken  from  the  heart  of  a  guinea-pig,  which  I  had  exposed  to  vapors 
from  a  freshly  painted  surface,  the  spectroscope  showed  the  presence  of 
carbon  monoxide. 

The  driers  which  are  added  to  paints  are  to  some  extent,  therefore, 
responsible  for  the  symptoms  complained  of  by  people  who  have  been  living 
in  newly  painted  houses.  Turpentine  is  a  drier,  lead  is  another,  so  too  are 
benzol,  benzine  and  petroleum  spirit.  Benzol  and  benzine  vapor  causes  dis- 
integration of  red  blood  corpuscles,  also  hemorrhages  on  mucous  membranes, 
and  tender  inflamed  gums,  conditions  which  recall  those  observed  in  scurvy. 

The  outcry  against  the  use  of  lead  has,  particularly  in  house  and  ship 
painting,  been  followed  by  the  introduction  of  various  substitutes.  For 
leadless  paints  the  demand  has  increased  during  recent  years.  Zinc  white 
is  being  more  widely  used  and  for  internal  decorative  purposes  it  answers 
quite  as  well  as  white  lead,  but  for  external  purposes  the  majority  of  master 
painters  prefer  lead  carbonate.  They  regard  its  covering  properties  and 
enduring  powers  as  superior  to  those  of  zinc.  Lithopone,  which  is  a  mixture 
of  zinc  sulphide  and  barium  sulphate,  is  also  coming  into  repute  in  house 
painting.  Space  will  not  permit  of  a  comparison  being  drawn  between  the 
various  forms  of  paints.  For  internal  decoration  it  may  be  said  that  zinc 
paints  give  all  the  covering  power  required  and  are  freer  from  danger  than 
lead  paints,  although  in  one  well-known  occasion  several  persons  became  ill 
where  zinc  paint  had  been  used  owing  to  the  presence  of  arsenic,  which  is 
frequently  present  in  zinc  and  which  in  this  particular  instance  had  not  been 
removed  after  smelting  of  the  ore.  The  ordinary  paints  in  use  have  distinctly 
bactericidal  properties.  Newly  painted  rooms  are  therefore  more  or  less 
aseptic. 

Between  1900  and  1909  there  were  reported  to  the  Home  Office  1973 
cases  of  lead  poisoning  with  380  deaths  of  house  painters.  Paralysis  of  the 
hands  and  fingers  is  extremely  common  in  house  painters.  Tancquerel  des 
Planches  found  paralysis  present  in  8  per  cent,  of  lead-poisoned  French  house 
painters,  Teleky  in  14.5  per  cent,  of  Austrian  painters,  and  Legge  in  22.7 
per  cent,  of  British  house  painters.  In  the  United  States  it  was  found  that 
one  in  every  six  painters  gave  a  history  of  having  had  plumbism  in  one  form 
or  another,  in  other  words  16.6  per  cent. 
6 


82  OCCUPATIONAL   INTOXICATIONS 

In  1898  the  number  of  cases  of  lead  poisoning  in  the  China  and  earthen- 
ware trades  had  been  so  large  as  to  call  for  Government  intervention.  The 
industry  is  chiefly  located  in  the  district  known  as  the  Potteries  in  New 
Staffordshire.  To  the  Potteries  Sir  Edward  Thorpe  and  I  were  sent  by  the 
Home  Secretary  to  enquire  into  the  prevalence  of  plumbism  among  the 
potters  and  to  make  such  recommendations  as  seemed  desirable.  When  we 
visited  New  Staffordshire  in  1898  Sir  Edward  Thorpe  and  I  found  several  of 
the  small  master  potters  using  glazes  for  their  ware  which  contained  20  to 
30  per  cent,  of  raw  lead.  Our  immediate  desire  was  to  reduce  the  percentage 
of  lead  used  in  the  glaze,  to  have  the  lead  fritted  and  therefore  rendered 
more  insoluble,  to  keep  women  away  from  the  dangerous  processes  and,  where 
possible,  to  substitute  leadless  for  lead  glazes.  In  a  modified  form  some  of 
these  recommendations  have  been  given  effect  to  and  will  be  of  distinct  benefit 
to  the  workers.  The  percentage  of  fatal  cases  of  lead  poisoning  in  persons 
employed  in  the  manufacture  of  pottery  is  small;  it  is  only  o.i  per  cent,  in 
persons  employed  in  lead  processes,  in  other  words  i  in  1000.  In  the  manu- 
facture of  earthenware  and  pottery  the  work-people  most  exposed  to  lead 
poisoning  are  the  dippers,  dippers'  assistants,  ware-cleansers  and  majolica 
paintresses.  It  is  when  glaze  containing  raw  carbonate  of  lead  becomes 
dried,  pulverized  and  raised  into  the  atmosphere  that  it  becomes  dangerous. 

Space  will  not  permit  my  mentioning  the  11 1  industries  in  which  Layet, 
a  French  physician,  tells  us  that  lead  is  employed.  File-cutting  need  only 
be  mentioned  as  one  of  those  unhealthy  industries,  the  manufacture  of 
electrical  accumulators  is  another,  so  too  are  printing,  Hnotyping,  calico 
dyeing  and  enamelling  of  metal  plates.  In  file-cutting  and  printing  other 
dangers  are  added.  Tuberculosis  claims  from  followers  of  those  occupations 
a  large  number  of  victims.  Lead  predisposes  to  tuberculosis  by  reducing 
the  vital  resistance  of  the  individual.  Printers  and  file-cutters  run  the  risk 
of  becoming  tuberculous  mainly  through  the  presence  of  tubercular  col- 
leagues and  the  fact  that  the  work  is  carried  on  in  rooms  too  highly  heated. 

Canned  food  and  fruit  are  sources  of  plumbism  owing  to  the  lead  in  the 
solder  becoming  acted  upon  by  any  acid  which  may  be  present. 

Men  employed  in  a  lead  factory  should  neither  chew  tobacco  nor  smoke 
when  at  work.  There  is  an  impression  among  the  men  that  chewing  tobacco 
is  a  preventive  against  plumbism.  Considering  the  opportunities  there 
are  of  loose  tobacco  in  the  waistcoat  pocket  coming  into  contact  with  lead 
dust,  also  the  fact  that  it  has  to  be  fingered,  there  is  nothing  to  encourage 
their  impression.     Experience  points  the  other  way. 

CHANNELS  OF  ENTRANCE  OF  LEAD  INTO  THE  BODY 

Through  the  skin  lead  can  be,  but  is  infrequently,  absorbed.  I  have  seen 
persons  become  the  subjects  of  plumbism  through  using  cosmetics  and  hair 
dyes  which  contained  lead.     The  main  channels  of  entrance  are  the  alimen- 


LEAD    POISONING  83 

tary  canal  and  the  lungs.  From  an  industrial  point  of  view  lead  in  the  form 
of  dust  is  the  enemy  to  be  guarded  against.  When  inhaled,  lead  dust  can 
reach  the  lungs  and  be  absorbed  from  the  respiratory  organs,  but  most  of  it  is 
caught  in  the  nasopharynx  and  is  swallowed.  The  experiments  of  Professor 
Lehmann  of  Wiirzburg  and  his  assistant,  Saito,  show  that  when  lead  dust  is 
inhaled  only  12  per  cent,  reaches  the  lungs  and  that  70  per  cent,  is  found  in 
the  alimentary  canal.  When  men  at  work  are  not  w^earing  respirators  much 
of  the  dust  enters  by  the  mouth  and  being  caught  there  is  dissolved  in  the 
saliva  and  swallow^ed.  On  reaching  the  stomach  it  is  acted  upon  by  the 
hydrochloric  acid  of  the  gastric  juice  and  converted  into  chloride  which  is 
soluble  and  capable  of  osmosis.  When  it  has  reached  the  blood  it  is  believed 
to  enter  into  combination  with  the  proteids  and  to  become  lead  albuminate, 
rather  an  insoluble  compound.  On  the  whole,  lead  carbonate  is  more 
soluble  in  the  gastric  juice  than  is  lead  sulphate.  If  food  is  being  digested 
at  the  same  time  less  lead  will  be  dissolved;  hence  the  desirability  of  men 
never  commencing  work  in  the  morning  without  first  having  had  food.  Lead 
undissolved  in  the  stomach  passes  out  in  the  feces  in  the  form  of  an  insoluble 
sulphide.  Some  of  the  lead  which  has  reached  the  blood  stream  is  elimi- 
nated by  the  kidneys.  If  not  thus  removed  some  of  it  may  pass  out  into 
the  tissues  where,  in  the  form  of  albuminate,  it  may  remain  for  months  or 
years  doing  no  harm  to  the  individual,  until  some  change  occurs  in  his 
metabolism  when  the  lead  becomes  redissolved  and  on  being  reabsorbed 
causes  symptoms  of  plumbism. 

Sjrmptomatology. — One  of  the  earliest  signs  that  a  workman  is  becoming, 
influenced  by  lead  is  a  gradually  increasing  pallor.  The  anaemia,  which  is 
fairly  quickly  progressive  at  first,  reaches  a  limit  and  ceases  to  proceed  farther 
unless  it  be  toward  a  deepening  cachexia.  It  might  therefore  be  expected 
that  the  blood  would  show  on  microscopical  examination  alteration  of  its 
structural  elements.  In  a  percentage  of  cases  varying  from  30  to  70  the  red 
corpuscles  or  erythrocytes  are  modified.  W^ith  any  of  the  Romanowsky's 
stains  several  of  the  erythrocytes  show  numerous  dark  dots  scattered  through 
their  contents.  These  punctated  cells  are  spoken  of  as  basophiles  and  when 
present  in  the  blood  in  large  number  the  condition  is  known  as  basophilia. 
Methylene  blue  gives  satisfactory  staining.  The  best  results  have  been 
obtained  by  using  a  formula  recommended  to  me  by  Dr.  Gilbert  of  Brussels. 
The  fluid  is  composed  of  methylene  blue,  2  grams;  sodium  bicarbonate,  12 
grams;  distilled  water  200  grams. 

The  film  of  blood  when  dried  is  steeped  in  absolute  alcohol  or  alcohol 
and  ether  for  half  an  hour,  then  dried,  afterward  steeped  for  i  minute  in  the 
above  solOtion,  removed  and  washed  in  distilled  water  until  the  color  almost 
fades,  when  it  is  dried  and  is  ready  for  examination. 

Ehrlich,  Grawitz  and  others  maintain  that  basophilia  is  diagnostic  of 
plumbism.  Anything  over  100  basophiles  per  1,000,000  red  corpuscles  is 
regarded  as  absolute  proof  of  lead  poisoning.     As  it  is  met  with  in  forms  of 


84  OCCUPATIONAL   INTOXICATIONS 

anaemia  in  no  way  associated  with  lead  poisoning,  basophilia  is  not  entitled 
to  this  unique  claim.  When  present,  basophiha  is  an  important  aid  in  the 
diagnosis,  but  it  is  frequently  absent  in  cases  where  it  ought  to  be  present  and 
it  is  present  where  it  is  least  expected.  I  do  not  attach  to  basophilia  the  im- 
portance some  physicians  ascribe  to  it  nor,  on  the  other  hand,  do  I  underrate 
its  value  in  certain  conditions.  It  has  not  been  found  that  basophilia  bears  a 
direct  relation  to  the  length  of  time  workmen  have  been  exposed  to  lead.  In 
workmen  with  a  well-marked  blue  line  on  the  gums  and  with  confirmed 
pallor  and  who  are  the  subjects  of  digestive  derangements  basophilia  may  be 
present,  but  in  many  instances  a  most  careful  examination  of  the  blood  fails 
to  reveal  more  than  one  or  two  basophile  corpuscles  in  the  whole  film.  What 
basophiha  is,  whether  a  degeneration  or  regeneration,  and  what  its  meaning, 
we  do  not  know.  In  1031  blood  examinations  made  in  the  Leipzig  Institute 
of  Hygiene,  basophilia  was  present  in  187  instances,  i.e.,  in  18.1  per  cent. 
Dr.  John  Russell  has  found  basophiles  in  pottery  workers  varying  in  number 
from  100  to  27,000  per  milhon.  It  is  because  of  other  substances,  e.g., 
nitrobenzene  and  anihne,  being  able  to  cause  basophilia,  also  of  the  presence 
of  basophilia  in  some  forms  of  anaemia  and  malaria,  that  we  are  disposed  to 
consider  the  value  of  basophilia  in  plumbism  as  overrated.  As  opposed  to 
Teleky  who  reminds  us  that  basophiles  are  present  in  the  blood  of  healthy 
persons,  P.  Schmidt  states  that  if  there  are  found  100  pi^nctated  erythrocytes 
per  million  red  corpuscles,  upon  this  fact  alone  a  diagnosis  of  plumbism 
may  be  made.  At  the  1906  Congress  of  Industrial  Diseases  in  Milan,  Biondi 
declared  that  he  had  not  found  basophile  erythrocytes  in  the  blood  of  persons 
suffering  from  severe  lead  intoxication.  On  the  other  hand,  Lutoslawsky 
in  1902  announced  that  of  107  persons  suffering  from  chronic  plumbism  only 
in  17  were  there  no  basophilic  corpuscles. 

It  may  be  stated  that  those  physicians  who  beheve  in  basophilia  as  a 
sign  of  lead  poisoning  maintain  that  it  is  in  the  early  stages  of  the  malady 
that  it  is  most  pronounced  and  that  even  in  this  respect  there  is  no  uniformity. 
It  is  possible  that  just  as  there  is  an  individual  idiosyncrasy  to  plumbism,  so 
in  those  who  are  becoming  lead  poisoned  the  blood  of  some  persons,  more 
than  others,  may  exhibit  a  greater  tendency  to  basophilia.  The  change  in 
the  red  blood  corpuscle  stained  greenish  blue  by  the  reagent  which  has  been 
used  reveals  itself  by  numerous  dark  dots  scattered  throughout  the  corpuscles 
and  is  not  the  general  bluish  coloration  of  the  corpuscle,  which  is  known  as 
polychromatophilia.  In  the  anaemia  of  lead  poisoning  there  is  a  distinct  reduc- 
tion in  the  number  of  red  blood  corpuscles.  Instead  of  the  normal  5,000,000 
erythrocytes  per  cu.  mm.  of  blood  there  may  be  only  3,000,000  to  3,500,000 
and  with  this  fall  in  the  number  of  red  corpuscles  there  is  a  corresponding 
diminution  in  the  amount  of  hemoglobin.  Basophiha  when  present  stands 
in  no  definite  relationship  to  the  amount  of  hemoglobin.  It  is  detected  in 
the  blood  of  men  who  are  following  their  occupation  in  lead  works  without 
discomfort  and  without  other  signs  of  plumbism.     There  is  no  Certifying 


LEAD   POISONING 


85 


Factory  Surgeon  who  would  on  the  mere  detection  of  basophiha  alone,  ir- 
respective of  special  reference  to  the  extent  of  it,  make  it  the  reason  for  sus- 
pending a  workman  from  the  factory.  In  70  per  cent,  of  my  cases  of  lead 
poisoning  basophilia  was  absent.  While,  therefore,  basophilia  is  an  aid  to 
the  diagnosis  of  plumbism  its  absence  is  no  proof  that  the  malady  investi- 
gated is  not  lead  poisoning. 

In  plumbism  the  white  corpuscles  of  the  blood  are  occasionally  increased 
in  the  direction  of  a  polymorphonucleosis,  but  on  the  whole  it  may  be  said 
that  numerical  and  structural  alterations  in  the  leucocytes  are  not  well 
marked. 

The  Blue  Line  on  the  Gums. — The  blue  line  on  the  gums  is  another  of 
those  signs  which  can  be  of  valuable  assistance  when  other  signs  or  symptoms 
are  present,  but  of  itself  is  no  proof  of  the  person  being  under  the  influence 
of  lead.  The  line  I  refer  to  is  situated  at  the  margin  of  the  gum  close  to  the 
teeth.  In  color  it  varies  from  a  Hght  slaty  blue  to  one  of  an  intenser  shade. 
Although  mostly  observed  on  the  gums  of  workmen  who  are  careless  in  the 
use  of  the  toothbrush  and  w^hose  gums  are  ulcerated,  I  have  found  it  where 
the  teeth  were  excellent  and  where  the  gums  were  healthy.  It  is  not  neces- 
sary', therefore,  to  have  a  preceding  gingivitis  to  cause  the  line,  although  such 
a  condition  of  the  gums  may  predispose  to  it.  If  the  mouths  of  several 
workmen  in  a  lead  factory  are  examined,  in  the  majority  of  them  a  blue  line 
wiU  be  detected  on  the  teeth  close  to  the  margin  of  the  gums.  This  type  of 
blue  line  is  observed  in  men  who  are  employed  in  a  dusty  lead  process  in  the 
factory.  It  is  not  the  true  Burtonian  line  but  is  simply  a  deposit  of  sulphide 
of  lead  on  the  teeth,  for  if  the  toothbrush  is  applied  or  the  mouth  rinsed  with 
warm  water  the  deposit  at  once  disappears.  In  the  typical  blue  hne  de- 
scribed by  Burton  an  actual  deposition  of  lead  sulphide  has  taken  place  in  the 
cells  of  the  deeper  layers  of  the  gum — by  cells  known  as  phagocytes.  No 
brushing  of  the  teeth  can  readily  remove  this  line.  It  may  persist  for  weeks 
or  months.  It  is  due  either  to  lead  which  has  been  dissolved  in  the  saliva  or 
to  lead  which  has  been  absorbed  and  comes  to  the  gums  by  the  blood  stream, 
becoming  acted  upon  by  the  sulphocyanide  of  potassium  present  in  the 
mouth,  or  by  sulphuretted  hydrogen  evolved  during  the  decomposition  of 
particles  of  food  retained  between  the  teeth  being  taken  up  by  the  phago- 
cytic cells  of  the  gums. 

A  blue  line  on  the  gums  is  of  great  value  in  diagnosis  when  other  signs  are 
also  present.  Even  where  other  signs  or  symptoms  of  plumbism  are  absent  it 
is  of  importance  to  note  its  presence  since  succeeding  events  may  reveal  its 
origin  and  meaning.  In  persons,  for  example,  who  are  taking  large  doses  of 
bismuth  or  who  are  having  fistulous  wounds  injected  with  bismuth  paste  a 
blue  line  may  appear  in  the  gums  practically  indistinguishable  from  that 
caused  by  lead.  Eliminating  such  a  possibility,  persistence  of  a  blue  hne  on 
the  gums  after  the  use  of  the  toothbrush  is  a  sign  not  so  much  of  lead  poison- 
ing as  of  lead  in  the  system  and  that  at  any  time,  consequent  upon  altered 


86  OCCUPATIONAL   INTOXICATIONS 

metabolism,  other  signs  or  symptoms  of  plumbism  may  show  themselves. 
The  diagnostic  value  of  the  blue  line  on  the  gums  must  therefore  neither  be 
overrated  nor  underrated,  since  in  many  cases  of  undoubted  plumbism  it  is 
absent  altogether.  No  investigation  of  a  suspicious  case  of  lead  poisoning  will 
be  complete  which  did  not  include  an  examination  of  the  gums. 

Occasionally  in  addition  to  a  blue  line  on  the  gums  there  may  be  observed 
inside  the  lip  or  on  the  inside  of  the  cheek,  opposite  a  decayed  tooth  or  one 
covered  with  tartar,  a  bluish-black  patch  the  size  of  a  three-penny  piece  or 
larger.  The  edges  of  the  patch  are  irregular.  It  is  due  to  friction  of  the 
mucous  membrane  against  the  unhealthy  tooth.  This  patch  is  confirmatory 
evidence  of  plumbism,  but  only  when  the  administration  of  bismuth,  for  ex- 
ample, can  be  excluded.  In  copper  workers  a  greenish-blue  line  is  frequently 
present  on  the  teeth.  This  line  is  not,  as  in  plumbism,  in  the  gums.  In 
pyorrhea  alveolaris  the  gums  occasionally  exhibit  a  delicate  blue  coloration, 
but  it  is  more  of  a  gentle  shading  than  a  definite  line. 

Colic  and  constipation  are  early  symptoms  of  lead  poisoning.  For 
several  days  before  the  onset  of  abdominal  pains  a  patient  may  have  expe- 
rienced a  disagreeable  secretion  in  the  mouth.  He  may  have  complained  of 
an  unpleasant  metallic  taste  and  of  an  accompanying  loss  of  appetite.  With- 
out further  warning  he  is  seized  with  severe  pain  in  the  abdomen  usually  in 
the  neighborhood  of  the  umbilicus.  The  abdomen  is  tender  to  the  touch, 
although  in  a  few  instances  relief  is  obtained  by  pressing  the  abdomen.  The 
pain  is  sometimes  so  severe  that  the  patient  is  with  difficulty  restrained. 
Vomiting  may  or  may  not  be  present.  In  other  instances  previous  to  colic 
there  may  be  obstinate  constipation.  The  bowels  may  be  closed  for  a  week 
and  opened  only  with  the  greatest  difficulty  by  the  aid  of  medicine.  Con- 
stipation usually  attends  upon  colic,  but  severe  abdominal  pain  may  continue 
after  the  bowels  have  been  relieved  by  medicine,  and  even  where  there  is 
diarrhea.  During  colic  Riegel  found  a  high  blood  pressure  which  he  attrib- 
uted to  constriction  of  the  arteries  in  the  splanchnic  area,  but  in  many  of  my 
patients  during  the  height  of  the  pain  the  blood  pressure  was  low,  the  pulse 
feeble  and  slow — only  30  to  40  beats  per  minute.  The  secretion  of  urine  falls 
to  4  and  6  oz.  for  the  24  hours.  The  cause  of  lead  colic  is  obscure.  In  ex- 
perimental plumbism  I  have  found  the  intestinal  canal  in  places  so  constricted 
by  muscular  spasm  as  to  have  the  caliber  completely  obliterated.  The  pain 
might,  therefore,  be  due  to  this  muscular  spasm  or  it  might  be  the  result  of  an 
effort  on  the  part  of  the  intestine  above  the  constriction  to  press  onward  the 
contents  into  the  contracted  portion  below.  Colic  can  hardly  be  due  to  con- 
stipation and  strong  peristaltic  contraction  of  the  bowel  to  propel  the  contents 
onward,  for  as  already  stated  the  pain  persists  when  there  is  diarrhea.  In  the 
course  of  2  or  3  days  the  severity  of  the  abdominal  pain  is  mitigated  but  there 
still  remains  uneasy  painful  sensations  which  become  aggravated  on  pressure, 
usually  worse  on  one  side  of  the  abdomen  than  on  the  other.  Accompanying 
this  type  of  pain  there  is  inequality  of  the  radial  pulses,  inequality  of  the 


LEAD    POISONING  87 

pupils;  also  pain  is  complained  of  when  pressure  is  made  along  the  course  of 
the  vagi  nerves  in  the  neck.  There  may  be  also  unilateral  sweating  of  a 
limb. 

Lead  colic  has  been  occasionally  mistaken  for  appendicitis  and  the 
abdomen  opened  by  a  surgeon  only  to  find  the  diagnosis  of  appendicitis 
unconfirmed. 

Headache.— When  present  in  plumbism  headache  is  usually  severe. 
The  pain  is  not  confined  to  any  particular  part  of  the  head.  It  may  or  may 
not  be  associated  with  albuminuria.  When  there  is  albumen  in  the  urine 
the  headache  is  probably  uraemic,  but  in  a  great  many  persons  the  urine  is 
quite  free  from  albumen.  The  headache  is  toxaemic,  none  the  less,  and  may 
be  due  to  lead  itself  or  to  poisonous  substances  formed  in  the  body  as  the  re- 
sult of  the  action  of  lead  upon  the  internal  organs.  Frontal  headache  may  be 
neuralgic  and  associated  with  arterial  spasm.  Severe  headache  is  occasionally 
the  forerunner  of  delirium  or  convulsions.  When  convulsions  occur  in  a  lead 
worker  they  are  of  grave  significance.  They  may  develop  without  albumen 
being  present  in  the  urine.  Convulsive  seizures  attended  by  coma  constitute 
what  is  known  as  saturnine  encephalopathy,  the  most  fatal  form  of  plumbism. 
In  females  saturnine  encephalopathy  may  be  preceded  by  symptoms  suggestive 
of  ordinary  hysteria,  but  the  symptoms  must  not  throw  the  medical  attendant 
off  his  guard  since  toxic  hysteria  frequently  gravitates  into  a  more  profound 
affection  of  the  central  nervous  system. 

Albuminuria  may  be  present  as  an  early  sign  of  plumbism  during  or  after 
an  attack  of  colic  and  it  may  disappear,  but  in  large  percentage  of  patients 
who  are  the  victims  of  chronic  lead  poisoning  it  persists  and  is  accompanied 
by  changes  in  the  blood-vessels  and  the  heart.  The  arteriosclerosis  may  be 
accompanied  by  an  elevated  blood  pressure.  To  old  lead  workers  death  fre- 
quently comes  by  cerebral  hemorrhage  and  at  the  autopsy  in  addition  to  the 
cerebral  lesions  the  kidneys  are  found  contracted.  Interstitial  nephritis  is 
the  condition  of  the  kidneys  found  in  the  late  stages  of  the  disease,  but  in  the 
early  stages  and  in  the  more  acute  forms  of  the  malady  the  lesion  affects  more 
the  cells  which  line  the  renal  tubules.  The  urine  of  lead  workers  frequently 
contains  lead. 

In  female  lead  workers  menstruation  is  increased;  in  those  who  are 
pregnant  the  tendency  is  for  miscarriage  to  take  place.  The  only  possible 
way  for  a  pregnant  female  to  reach  full  term  is  to  retire  from  the  work  at  the 
earliest  possible  date.  I  am  disposed  to  believe  that  one  of  the  reasons  why 
females  are  more  readily  influenced  for  harm  by  lead  than  men  is  the  peculiar 
action  of  lead  upon  the  reproductive  organs. 

Cerebral  plumbism  has  occasionally  been  diagnosed  as  tumor  of  the  brain 
and  a  portion  of  the  calvarium  has  been  removed  to  give  relief  to  the  headache 
and  pressure.  The  symptoms  are  not  unlike  cerebral  tumor:  there  are  severe 
headache,  vomiting  and  possibly,  too,  retinal  changes.  Should  the  patient 
who  has  been  the  subject  of  convulsions  recover,  it  may  be  that  the  eyesight 


88  OCCUPATIONAL   INTOXICATIONS 

is  lost.  The  loss  of  vision  in  lead  poisoning  is  threefold:  (i)  There  are  no  in- 
traocular changes  observed  in  the  retina;  (2)  the  discs  are  hypersemic,  swollen 
and  mottled  and  their  edges  are  irregular,  the  outline  of  the  vessels  is  obscured 
and  there  are  retinal  hemorrhages;  and  (3)  there  are  delicate  white  lines  ex- 
ternal to  the  retinal  vessels,  there  are  hemorrhages  and  albumen  is  present  in 
the  urine.  In  the  first  form  of  loss  of  vision  the  cause  is  toxic  or  there  is  spasm 
of  the  arteries,  for  vision  may  be  soon  regained  and  no  after-effects  be  left 
behind.  In  the  second  form  we  have  the  typical  amaurosis  of  lead  poisoning, 
viz.,  retinal  hemorrhages  and  swollen  discs.  Here  vision  may  never  be  quite 
regained.  When  formerly  women  were  allowed  to  work  in  the  white  lead 
factories  saturnine  encephalopathy  followed  by  loss  of  sight  was  not  of  in- 
frequent occurrence.  Since  women  have  been  excluded  from  the  dangerous 
processes  of  lead  manufacture  this  severe  type  of  plumbism  has  almost  en- 
tirely disappeared.  It  is  not  exactly  known  how  the  intraocular  changes  are 
brought  about.  Some  physicians  are  of  the  opinion  that  lead  induces  effusion 
into  the  subarachnoid  space  of  the  brain  and  thereby  causes  distention  of  the 
sheath  of  the  optic  nerve  with  pressure.  In  one  of  my  patients  who  died  from 
saturnine  encephalopathy  there  was  found  on  microscopical  examination  of 
the  optic  nerve  round-celled  infiltration  of  the  fibrous  trabeculae  between 
the  bundles  of  nerve  fibers,  the  infiltration  being  most  marked  at  the  posterior 
portion  and  for  some  distance  behind  the  lamina  cribrosa.  In  persons  dying 
from  acute  plumbism  with  nervous  phenomena  small  hemorrhages  were  found 
by  Mosny  of  the  Hospital  St.  Antoine,  Paris,  in  the  cortex  of  the  brain. 
Miliary  hemorrhages  were  found  by  F.  W.  Mott  in  the  perivascular  sheaths 
of  the  small  vessels  of  the  cortex  and  in  the  substance  of  the  brain  in  a  coach 
painter  who  had  epileptic  seizures.  Goadby  also  found  minute  hemorrhages 
at  the  base  of  the  brain  and  on  the  vortex. 

Nervous  System, — ^Lead  exhibits  a  predilection  for  nerve  tissue.  Not  only 
are  the  peripheral  nerves  liable  to  become  affected  but  the  cells  of  the  central 
nervous  system  as  well.  Within  recent  years,  owing  to  the  great  improve- 
ment in  the  conditions  of  labor  in  lead  factories,  opportunities  for  studying 
the  pathology  of  acute  plumbism  have  become  extremely  rare.  We  are 
familiar  with  the  paralyses  of  the  fingers  and  hands  which  takes  place  in  lead 
workers,  but  persons  thus  afflicted  seldom  die  in  this  stage  of  the  illness. 
Paralysis  of  both  wrists,  the  so-called  wrist-drop,  is  characteristic  of  lead 
poisoning.  Usually  both  hands  are  affected,  a  circumstance  which  suggests 
that  a  general  cause  such  as  a  toxaemia  has  been  in  operation.  Occasionally, 
however,  one  wrist  alone  is  affected  but  the  other  will  probably  be  found  to  be 
be  paretic.  Generally  speaking,  the  paralysis  is  more  marked  on  the  outside 
of  the  body  the  muscles  of  which  are  more  actively  employed.  Teleky 
therefore  thinks  that  fatigue  is  a  contributory  cause  of  the  paralysis  of  plum- 
bism. The  influence  of  previous  muscular  strain  cannot  be  altogether  ig- 
nored. It  has  generally  been  taught  that  the  loss  of  power  in  the  muscles  in 
lead  paralysis  is  due  to  a  lesion  of  the  peripheral  nerves,  an  interstitial  neu- 


LEAD    POISONING  89 

ritis;  but  Goadby,  finding  minute  hemorrhages  in  groups  of  paralyzed  muscles 
of  which  strain  at  work  may  have  been  a  cause,  as  well  as  minute  hemorrhages 
in  the  nerves  supplying  those  muscles,  regards  the  lesion  as  neuro-muscular. 

The  common  type  of  paralysis  found  in  lead  workers  is  "wrist-drop." 
The  patient  is  unable  to  extend  the  wrists.  The  muscles  involved  are  the 
extensors  of  the  wrists,  the  interossei  extensors  of  the  fingers.  The  supinators 
usually  escape.  This  form  of  paralysis  renders  the  individual  extremely 
helpless.  In  the  brachial  type  of  paralysis  the  deltoid,  triceps,  brachiahs 
anticus  and  supinator  longus  are  affected  along  with  the  supra  and  infra- 
spinati.  In  yet  another  form,  the  Aran-Duchenne  type,  the  muscles  affected 
are  those  of  the  outer  border  of  the  hand,  also  those  of  the  thumb  including  the 
interossei.  Accompanying  these  there  are  atrophy  and  fibrillary  tremor  of 
such  a  degree  as  to  suggest  muscular  atrophy.  Although  lead  paralysis 
usually  affects  the  muscle  of  the  upper  extremity  in  correlated  groups  yet  it 
may  be  irregular,  more  on  one  side  than  the  other;  also  in  children  the  peroneal 
muscles  and  the  extensors  of  the  toes  may  be  the  only  muscles  involved.  The 
tibialis  anticus  as  a  rule  escapes.  The  peroneal  type  of  lead  paralysis  may 
occur  alone  or  it  may  be  associated  with  wrist-drop.  I  have  seen  this  form  of 
loss  of  power  in  the  adult  as  part  of  a  widely  distributed  paralysis  in  which 
the  muscles  of  the  limbs,  the  back  and  pelvis  were  involved.  Such  widely 
distributed  paralysis  is  extremely  dangerous  owing  to  the  possibility  of  the 
intercostal  muscles  becoming  affected  and  of  respiration  being  rendered 
almost  impossible.  Fortunately  my  own  patients  recovered,  but  death  is 
known  to  have  come  from  respiratory  paralysis.  The  muscles  of  the  larynx 
may  become  affected,  also  those  of  the  bladder,  but  a  much  more  frequent 
development  is  paralysis  of  the  muscles  of  the  eyeball  causing  diplopia. 

Persons  who  are  working  in  lead  or  who  are  the  victims  of  plumbism 
frequently  complain  of  ill-defined  pains  in  the  limbs.  The  pains  are  spoken 
of  as  rheumatic.  They  may  possibly  be  due  to  limited  patches  of  neuritis. 
Occasionally  before  wrist-drop  occurs,  pain  in  the  arms  is  complained  of 
but  once  paralysis  is  developed  pain  is  not  a  common  complaint.  The  re- 
flexes are  not  uniformily  affected.  They  may  be  increased;  more  frequently 
they  are  diminished.  Tremor  of  the  labio-facial  muscles  is  common  and  can 
be  usually  demonstrated  by  asking  the  individual  to  show  his  teeth. 

In  a  few  male  lead  workers  of  35  to  45  years  of  age,  who  have  signs  of 
plumbism,  there  develops  an  uneven  gait,  slow  and  interrupted  speech, 
fibrillary  tremor  of  the  tongue  and  of  the  nasolabial  muscles,  defective  memory 
and  unequal  pupils.  The  knee-jerks  are  diminshed  or  absent.  The  symptoms 
suggest  general  paralysis  but  there  is  nothing  of  the  exaltation  of  ideas  nor 
of  the  uncertain  temper  met  with  in  ordinary  general  paralysis.  Saturnine 
pseudo-general  paralysis  can  be  recovered  from.  This  circumstance  marks  it 
off  from  the  better  known  malady.  Practically  all  general  paralytics,  in 
consequence  of  the  syphilitic  origin  of  their  illness,  give  a  positive  Wassermann 
reaction.     Many    lead-poisoned    patients    respond    in    a    similar    manner 


go  OCCUPATIONAL   INTOXICATIONS 

but  while  the  Wassermann  reaction  complicates  matters  it  does  not  prove 
that  the  pseudo-general  paralysis  of  plumbism  is  of  specific  origin.  Through 
the  kindness  of  Dr.  Irvine,  Dr.  Shade,  Bacteriologist  Royal  Victoria  Infirmary 
and  I  have  been  able  to  examine  several  men  and  women  in  a  lead  factory. 
In  our  first  examination  ii  men  varying  in  age  from  23  to  58  were  taken — 
4  of  them  had  a  well-marked  blue  line.  In  8  of  these  men  the  results 
were  positive;  in  3  negative.  In  another  series  of  diflferent  workmen, 
some  with  blue  lines  on  gums,  4  gave  positive  results  and  7  negative. 
Of  9  female  lead  workers  2  gave  a  positive  reaction  and  7  negative. 
In  another  series  of  examinations  of  8  male  workers  3  gave  a  positive 
reaction  and  5  negative.  Of  39  lead  workers  thus  examined  in  the  factory 
17  gave  a  positive  Wassermann  reaction  and  22  a  negative,  the  percentages 
being  43.6  and  56.4  respectively.  It  would  almost  seem  as  if  a  slowly  de- 
veloping plumbism  and  not  past  or  latent  syphilis  was  responsible  for  the 
positive  reaction  in  these  cases.  The  absence  of  a  specific  history  on  the 
part  of  a  patient  is  of  no  importance  in  the  diagnosis  of  syphilis  but  enquiry 
into  the  past  with  a  careful  appreciation  of  the  present  conditions  is  a  guide. 
In  the  largest  percentage  of  the  male  and  female  workers  who  gave  a  positive 
reaction  syphilis,  in  my  opinion,  could  be  excluded.  It  is  an  interesting  fact 
that  a  lead  patient  who  gives  a  Wassermann  positive  reaction  may  later  on 
return  a  negative.  The  precise  meaning  of  a  positive  Wassermann  reaction 
in  a  large  precentage  of  lead  workers  is  not  yet  forthcoming.  It  must  always 
be  borne  in  mind  that  lead  workers  are  like  other  people,  not  free  from 
syphilis,  so  that  while  in  some  instances  a  lead-poisoned  person  is  also  syphi- 
litic, a  circumstance  to  which  the  symptoms  suggesting  general  paralysis  may 
justly  be  attributed,  there  are  others  presenting  similar  symptoms  who 
neither  are  nor  have  been  the  subjects  of  syphilis. 

When  and  how  long  after  exposure  to  the  metal  either  in  the  form  of  dust 
or  fume,  symptoms  of  lead  poisoning  will  show  themselves  it  is  impossible 
to  say.  In  those  patients  by  whom  diachylon  has  been  taken,  it  is  usually 
2  or  3  weeks  before  such  a  sign  as  paralysis  appears  even  though  the  patient 
may  have  had  colic  for  several  days.  Much  depends  upon  the  susceptibility 
of  the  individual  to  lead  and  the  amount  of  dust  or  fume  he  is  exposed  to. 
Some  persons  are  more  readily  influenced  by  lead  than  others.  Females 
and  young  persons  are  more  predisposed  to  plumbism  than  males  and  persons 
of  mature  years.  One  of  my  patients  developed  signs  of  lead  poisoning  i 
week  after  making  electrical  accumulators  in  a  small  room.  Dr,  Alice  Hamil- 
ton found  in  hospital  a  white  lead  worker  suffering  from  colic  and  neuritis. 
He  had  worked  in  the  factory  only  3  days.  Of  120  patients  whom  she 
examined  eight  had  become  ill  in  less  than  2  weeks  after  commencing  work, 
36  in  less  than  a  month  and  89  in  less  than  a  year. 

Colic  may  occur  early  in  some  persons,  i  to  6  weeks  after  exposure  to  lead. 
There  is  no  stated  time  for  signs  or  symptoms  to  appear.  It  is  largely  a 
question  of  individual  predisposition.     Equally  difficult  is  it  to  state  the 


LEAD   POISONING 


91 


amount  of  lead  which  is  capable  of  creating  ill  health.  All  physicians, 
however,  agree  that  plumbism  is  much  more  likely  to  develop  and  the  symp- 
toms to  be  more  severe  when  small  doses  of  the  poison  pass  into  the  body  over 
a  lengthened  period  of  time  than  when  only  one  or  two  large  doses  are  taken. 
The  system  can  absorb  only  minute  quantities  of  lead  at  a  time.  When, 
therefore,  one  or  two  large  doses  are  taken,  the  bulk  of  the  poison  is  expelled 
in  the  feces.  As  regards  drinking  water  Angus  Smith  and  Professor  Rubner 
tell  us  that  0.36  mg.  of  lead  per  liter  of  water  is  the  limit  of  safety.  In  the 
famous  Orleans  case  of  38  persons  living  at  Castle  Clermont,  13  became  ill 
after  having  drunk  during  a  period  of  a  few  months  water  which  contained 
0.2  to  1.5  mg.  of  lead.  Teleky  is  of  the  opinion  that  if  i  mg.  or  a  little  more 
of  lead  is  taken  daily  for  several  months,  it  wdll  cause  plumbism.  A  daily 
dose  of  10  mg.  would,  in  the  course  of  a  few  weeks,  be  followed  by  serious 
symptoms. 

The  bulk  of  industrial  lead  poisoning  is  caused  by  persons  breathing  fumes 
or  inhaling  dust.  Kaup  found  in  the  air  of  the  drying  ovens  in  a  white  lead 
factory,  taken  at  the  level  of  the  face  of  the  workmen,  0.134  mg.  of  lead. 
Miiller  found  in  the  air  of  a  lead  smelting  works  236.8  mg.  of  lead  in  100  Hters 
of  atmospheric  air.  As  during  a  working  day  of  10  hours  4.5  cubic  meters  of 
air  could  be  carried  into  the  lungs  there  would  be  inhaled  amounts  of  lead 
varying  from  6  to  25.2  mg.  Similarly,  as  in  paint  mixing  and  dry  color  grind- 
ing, there  may  be  0.178  to  0.25  mg.  of  lead  per  100  liters  of  air,  workmen 
thus  exposed  run  the  risk  of  becoming  lead  poisoned.  \\'Tien  we  add  to  the 
above  the  dust  adherent  to  the  fingers  and  hands,  the  hair  and  mustaches, 
and  the  clothing  and  boots  of  work-people,  the  opportunities  for  plumbism 
are  many. 

Whether  it  is  absorbed  through  the  lungs  or  through  the  stomach  and 
upper  part  of  the  small  intestines  lead  enters  into  close  alliance  with  the 
proteid  of  the  blood,  forming  an  albuminate,  rather  an  insoluble  compound. 
This  remains  soluble  in  a  neutral  solution  but  the  slightest  degree  of  acidity 
or  of  alkalinity  as  already  stated,  tends  to  render  it  insoluble,  a  circumstance 
which  explains  the  inertness  of  lead  albuminate  when  deposited  in  the  tissues 
— also  the  fact  that  lead  which  has  lain  long  latent  in  the  system  and  caused 
no  symptoms  suddenly  and  unexpectedly  gives  rise  to  these  in  consequence 
of  altered  metabolism.  Since  the  bulk  of  lead  which  enters  the  body  has 
passed  in  through  the  alimentary  canal,  the  liver  and  spleen  after  death 
are  the  organs  which  are  found  to  contain  it  in  largest  quantities,  but  lead 
is  also  found  in  the  brain,  muscles  and  kidneys. 

Diagnosis. — The  diagnosis  of  plumbism  may  be  comparatively  simple  or, 
owing  to  anomalous  symptoms,  it  may  be  extremely  difficult  and  especially 
is  this  the  case  in  industrial  lead  poisoning  where  the  question  of  compensa- 
tion is  concerned.  Given  a  history  of  exposure  to  the  metal,  a  blue  line  on 
the  gums  and  a  history  of  colic  with  or  without  wrist-drop  there  can  be  little 
or  no  doubt  about  the  diagnosis.     The  cases  which  are  obscure  are  those 


92  OCCUPATIONAL   INTOXICATIONS 

in  which  there  is  no  history  of  exposure  to  lead  and  no  blue  line  on  the  gums 
but  a  story  of  indifferent  health  of  headache  and  anaemia,  with,  it  may  be, 
paralysis  of  the  muscles  of  the  eyeball.  Microscopical  examination  of  the 
blood  may  reveal  basophilia  which,  if  not  due  to  a  recognizable  form  of  anaemia, 
will  be  of  assistance  in  coming  to  a  determination.  The  detection  of  lead  in 
the  urine  is  of  greater  importance.  It  does  not  follow,  however,  because 
lead  is  found  in  the  urine  that  therefore  the  case  is  one  of  plumbism  for  the 
man  or  woman  may  not  be  ill  but  it  shows  that  lead  is  in  the  system,  is  being 
eliminated  and  that  a  check  to  elimination  might  at  any  moment  be  followed 
by  active  signs  and  symptoms  of  the  malady.  The  harboring  of  lead  within 
the  body  or  its  ehmination  by  the  urine  and  feces  in  small  quantities  without 
the  individual  being  ill  places  him  in  the  same  position  as  a  typhoid  carrier. 
A  female  lead  worker  will,  for  example,  bring  forth  a  still-born  infant,  or  a 
child  who  dies  a  few  hours  after  birth,  in  whose  organs  lead  is  found  on  chem- 
ical examination,  without  herself  having  shown  either  signs  or  symptoms  of 
plumbism.  In  patients  who  have  become  ill  through  drinking  water  con- 
taminated by  lead  there  may  be  none  of  the  ordinary  symptoms  of  plumbism. 
There  may  be  gradual  loss  of  health,  headache,  sleeplessness,  inability  to 
apply  oneself  to  work,  deranged  appetite  and  extreme  depression  of  spirits 
without  any  blue  line  on  the  gums  or  history  of  colic,  without  basophilia 
too,  and  yet  traces  of  lead  may  be  found  in  the  urine.  Then,  too,  it  may 
be  that  after  attacks  of  recurrent  abdominal  pain  had  been  dignosed  and 
treated  as  dyspeptic  the  individual  develops  gout  and  albuminuria  which  are 
indirectly  the  result  of  the  action  of  lead. 

Treatment. — The  treatment  of  lead  poisoning  is  preventive  and  curative. 
Drinking  water  gathered  in  a  peaty  soil  should  have  its  plumbosolvency  tested 
two  or  three  times  a  year  and  dealt  with  accordingly.  Various  suggestions 
have  been  offered  whereby  substitutes  may  be  found  for  lead  pipes,  but  none 
of  them  are  readily  taken  up  by  architects.  In  lead  factories  everything 
possible  must  be  done  to  prevent  the  escape  of  fumes  and  dust  into  the 
atmosphere  of  the  place  when  work  is  being  carried  on.  Exhausts  should  be 
introduced  wherever  possible.  This  recommendation  is  better  than  the  wear- 
ing of  respirators.  The  work-people  themselves  can  be  of  great  assistance  by 
keeping  themselves  clean,  taking  warm  baths  frequently  and  never  touching 
food  without  first  washing  the  hands  and  rinsing  the  mouth.  Females  should 
not  be  allowed  to  work  in  the  dangerous  processes  of  any  lead  industry. 
Almost  the  first  complaint  for  which  a  lead  worker  seeks  advice  is  colic.  Pre- 
vious to  this  friends  may  have  observed  that  such  and  such  a  workman  was 
becoming  anaemic,  but  at  this  stage  of  the  development  of  plumbism  it  is  rare 
for  medical  advice  to  be  sought.  Formerly  in  lead  works  in  the  hope  of  ward- 
ing off  colic  employers"  supplied  the  work-people  with  an  acid  lemonade  in 
which  magnesium  sulphate  was  dissolved.  It  was  of  doubtful  benefit.  The 
good  effected  was  mostly  through  the  beverage  acting  as  an  aperient.  It  gave 
a  false  security  to  the  workers.     In  some  lead  factories  tabloids  of  calcium 


LEAD    POISONING  93 

sulphide,  i  grain,  are  given  almost  daily  to  the  men.  Whether  in  consequence 
of  or  despite  this  simple  prophylaxis,  it  must  be  stated  that  the  men  in  these 
factories  have  kept  remarkably  well  in  health. 

When  colic  is  severe  the  patient  must  be  kept  warm  in  bed,  if  possible, 
and  hot  applications  applied  to  the  abdomen.  As  there  is  usually  constipa- 
tion an  enema  may  be  given  or  a  dose  of  castor  oil  administered  by  the  mouth. 
In  severe  cases  of  constipation  accompanying  colic,  should  the  castor  oil  or 
any  other  aperient  not  have  acted,  i  drop  of  croton  oil  on  a  piece  of  sugar 
may  be  given  by  the  mouth.  Sometimes  the  pain  is  so  excruciating  that 
morphine  has  to  be  injected.  The  abdominal  pain  can  be  relieved  by  the 
administration  of  sodium  mono-sulphate  in  3^^-  or  i -grain  doses  thrice  daily. 
Dr.  Stevens  of  Cardiflf  has  found  the  internal  administration  of  }:4-grain 
dose  of  calcium  permanganate  helpful. 

For  colic  and  constipation  a  mixture  of  potassium  iodide  and  sulphate  of 
magnesium  with  a  bitter  is  much  resorted  to.  Care  should  be  taken  in  the 
administration  of  potassium  iodide  that  the  dose  to  commence  with  is  small, 
for  potassium  iodide  has  the  power  of  dissolving  lead  lying  inert  in  the  tissues, 
of  causing  it  to  be  reabsorbed,  and  as  this  circulates  through  the  body  it  may 
induce  a  fresh  attack  of  plumbism.  To  the  iodide  and  magnesium  sulphate 
mixture  5  drops  of  tinct.  nux  vomica  with  a  carminative  may  be  added.  Mas- 
sage and  electricity  should  be  prescribed  in  cases  of  paralysis  which  are  re- 
covering slowly.  During  epileptiform  seizures  the  bowel  should  be  washed 
out  with  mustard  and  warm  water,  a  tablespoonful  of  mustard  to  a  pint  of 
•  water,  and  afterward  an  enema  containing  30  or  40  grains  of  bromide  should 
be  administered  per  rectum. 

For  chronic  plumbism  and  where  there  are  anaemia,  albuminuria,  head- 
ache, loss  of  vision  and  oedema  of  feet  the  medical  treatment  resolves  itself 
largely  into  one  of  symptoms.  It  is  not  absolutely  necessary  in  every  in- 
stance when  albumin  has  been  found  in  the  urine  of  old  lead  workers  who  have 
no  symptoms  to  suspend  these  men  from  employment.  Removal  from  work 
will  not  effect  a  cure.  These  men  live  longer  and  are  happier  if  they  are 
allowed  to  go  to  the  factory,  do  light  work  when  there  and  receive  wages  for 
doing  so. 

In  addition  to  the  above  another  method  of  treatment  can  be  recom- 
mended, especially  for  lead  workers.  It  is  both  preventive  and  curative, 
known  as  the  Clague-Oliver  method — it  is  an  extension  of  the  electrical 
treatment.  The  object  to  be  obtained  is  primarily  removal  of  lead  from  the 
body  if  any  be  present  therein,  and  secondly  the  bracing  up  and  stimulating 
effect  of  the  electricity.  The  story  of  the  double  electrical  bath  treatment 
is  briefly  this:  I  had  produced  experimental  plumbism  in  a  rabbit.  The 
animal  was  paralyzed  in  its  limbs.  It  struck  me  as  the  animal  had  received 
a^considerable  quantity  of  lead  by  the  mouth  that  if  the  metal  could  be  re- 
moved from  the  body  it  might  recover.  Accordingly  I  consulted  with  Mr. 
T.  M.  Clague  of  Newcastle-upon-Tyne,  and  he  suggested  that  by  means  of  a 


94  OCCUPATIONAL   INTOXICATIONS 

double  electrical  bath  we  might  succeed  in  accomplishing  this  object. 
Placing  the  forelimbs  of  the  animal  in  one  bath  containing  an  electrode 
(positive)  and  the  hind  limbs  in  another  containing  another  electrode 
(negative),  the  chest  and  abdomen  of  the  animal  resting  on  a  pad  of  cotton 
between  the  two  baths,  a  current  of  15  volts  and  a  milliamperage  of  20  was 
allowed  to  pass  through  the  animal  for  a  little  less  than  an  hour.  In  the 
course  of  a  few  baths  the  paralysis  had  disappeared  and  the  animal  was  quite 
well.  On  chemical  examination  of  the  electrodes  and  the  bath-water  lead 
was  found.  Subsequently  lead  was  administered  to  the  animal  and  again 
it  became  paralyzed.  Double  electrical  treatment  soon  restored  the  animal 
to  health  again.  Several  months  afterward  lead  was  again  given  to  the  rabbit 
and  for  a  third  time  it  became  paralyzed.  No  bath  was  given;  the  animal 
died.  From  its  spleen  and  liver  lead  was  extracted.  Altogether,  in  the 
course  of  3  years  this  animal  had  received  by  the  mouth  1.096  grains  of  nitrate 
of  lead,  the  equivalent  of  684  grains  of  metallic  lead.  Having  succeeded  in 
restoring  to  health  an  animal  which  had  been  poisoned  by  lead  it  seemed 
that  in  industrial  lead  poisoning  there  was  a  possible  field  for  the  application 
of  the  double-bath  electrical  treatment.  I  have  tried  it  in  many  cases  with 
encouraging  results.  Under  its  influence  the  blue  line  on  the  gums  disappears 
more  quickly  than  with  medicine,  paralysis  is  recovered  from  more  quickly 
and  the  duration  of  colic  is  shortened.  Dr.  Patterson  of  Philadelphia  has 
had  unusual  success  in  the  treatment  of  colic  by  it.  As  a  preventive  an  elec- 
trical bath  taken  once  a  week,  or  at  the  most  twice  a  week,  keeps  the  work-people 
in  better  health  than  the  use  of  the  weekly  warm  full  bath  recommended  by 
the  Home  Office.  A  lead  worker  who  is  absorbing  the  metal  keeps  free  from 
symptoms  owing  to  the  fact  that  the  daily  elimination  of  lead  from  his  body 
remains  equal  or  is  slightly  larger  than  the  intake.  The  double  electrical 
bath  favors  elimination.  The  drawbacks  to  it  are  that  where  the  skin  is 
in  contact  with  the  salt  water  there  may  be  slight  irritation  or  itching  of  the 
skin;  a  mild  dermatitis  may  follow.  If  the  bather  touches  the  electrode 
with  his  hand  or  foot  there  may  be  painful  redness  followed  by  superficial 
ulceration.  It  might  be  thought  that  if  by  electrolysis  lead  can  be  re- 
moved from  the  body,  other  metals  useful  to  the  economy,  e.g.,  iron,  might  also 
be  removed.  Experiment  shows  that  lead  is  the  more  electrolizable  of  the 
two  metals  and  that  lead  is  not  only  the  first  metal  to  be  removed  but  that  it 
always  comes  away  in  larger  quantity  than  iron.  It  is  desirable  to  let  the 
work-people  have  the  bath  at  the  close  of  the  day's  work  since  they  can  go  home 
afterward  and  take  matters  quietly  for  a  period.  As  a  preventive  the  bath 
should  be  given  for  at  least  15  to  20  minutes  once  a  week;  as  a  curative  agent 
it  should  be  taken  every  second  or  third  day.  Quite  apart  from  the  de- 
batable point  of  whether  lead  is  or  is  not  removed  from  the  body,  the  elec- 
trical baths  have  a  distinctly  bracing  up  and  stimulating  influence  upon  the 
workers.     It  is  at  any  rate  a  line  of  treatment  well  worthy  of  a  prolonged  trial 


LEAD   POISONING  95 

but,  like  all  other  forms  of  treatment,  suitable  cases,  that  is,  those  with  not 
too  advanced  structural  alteration  of  organs,  should  be  chosen. 

REFERENCES 

^  The  Action  of  Water  on  Lead  Service  Pipes.     Public  Works,  Jan.,  1914. 

*  U.  S.  Naval  Medical  Bulletin,  Apr.,  1912,  page  161,  Washington,  D.C.,  Government 

Printing  Office. 
'  Bulletin  Xo.  41,  1914,  Paint  Manufacturers'  .Association  of  the  United  States. 


EARLY  DIAGNOSIS  OF  LEAD  POISONING 

BY  H.  LINEXTHAL,  M.    D..  Boston,  Mass. 

Early  diagnosis,  important  in  every  case  of  ill  health,  assumes  especial 
importance  in  those  diseases  which  are  preventable,  and  in  which  the  interest 
of  public  health  demands  that  measures  be  taken  to  eradicate  the  conditions 
which  give  rise  to  them.  The  importance  of  early  diagnosis  in  communicable 
diseases  has  been  dwelt  upon  repeatedly  in  recent  years.  In  tuberculosis, 
for  instance,  we  have  learned  that  our  only  chance  of  arresting  the  disease, 
of  restoring  the  patient  to  health,  and  of  removing  a  focus  of  infection  is 
to  recognize  the  disease  in  its  incipiency.  Likewise,  the  early  diagnosis  of 
cases  of  typhoid  fever,  scarlet  fever,  diphtheria  and  other  communicable 
diseases  may  call  attention  promptly  to  the  source  of  infection  and  prevent 
the  occurrence  of  many  other  cases.  With  equal  force  does  this  apply  to 
occupational  diseases.  We  must  learn  to  diagnose  them  in  their  incipiency 
if  we  would  protect  the  worker  from  the  more  serious  manifestations  of  these 
diseases,  and  if  we  would  institute  preventive  measures  against  the  occur- 
rence of  other  cases. 

Lead  intoxication,  on  account  of  the  great  variety  of  industries  in  which 
the  metal  or  its  salts  are  used,  is  the  most  prevalent  of  occupational  diseases. 
While  the  diagnosis  in  a  well-marked  case  is  usually  not  difficult,  it  may  not 
be  so  clearly  defined  in  the  early  stages  of  the  intoxication.  The  tendency 
among  physicians  generally  is  not  to  make  the  diagnosis  unless  the  objective 
signs  are  found,  which  are  supposed  to  be  pathognomonic  of  the  disease. 
This  tendency  to  postpone  the  diagnosis  in  the  absence  of  certain  objective 
signs  is  dangerous  and  often  does  incalculable  harm.  The  physician  who 
fails  to  recognize  tuberculosis,  for  instance,  without  the  presence  of  tubercle 
bacilli  in  the  sputum  very  often  fails  to  avail  himself  of  the  opportunity  of 
arresting  the  disease  in  its  incipiency.  The  same  is  true  of  lead  poisoning. 
The  waiting  for  certain  signs  before  establishing  the  diagnosis  may  permit 
the  poison  to  undermine  the  constitution  of  the  worker  beyond  any  remedial 
measures,  and  may  delay  preventive  measures  against  the  source  of  the 
intoxication.  The  objective  signs  supposed  to  be  pathognomonic  of  lead 
poisoning,  the  presence  of  one  or  more  of  which  is  still  regarded  by  many 
physicians  as  absolutely  necessary  before  a  diagnosis  can  be  made,  are  the 
lead-line  on  the  gums,  basophilic  degeneration  of  the  red  cells  and  the  pres- 
ence of  lead  in  the  urine  and  stools. 

The  technical  difficulty  of  testing  for  lead  in  the  urine  and  stools  is  so 
great  as  to  preclude  such  a  test  from  a  part  of  the  routine  examination  in 

96 


EARLY    DIAGNOSIS    OF    LE.AD    POISONING  97 

general  practice.  Moreover  the  presence  of  lead  in  the  excretions  is  not 
constant  even  in  well-marked  cases  of  lead  poisoning.  On  the  other  hand, 
lead  has  often  been  found  in  the  urine  and  more  frequently  in  the  stools  of 
persons  exposed  to  lead  who  do  not  show  any  evidence  of  intoxication. 

•  The  presence  of  the  lead-line  and  the  basophilic  degeneration  of  the  red 
cells,  are  objective  findings  which  are  of  practical  use  in  the  diagnosis  of 
lead  poisoning.  As  a  matter  of  fact,  neither  one  of  these  signs  is  pathog- 
nomonic of  the  disease,  and  while  their  presence  is  a  valuable  aid  in  the 
diagnosis  of  obscure  cases,  their  absence  should  not  be  given  undue  weight 
against  the  diagnosis  of  lead  poisoning  Vv-hen  a  history  of  definite  exposure 
to  lead  can  be  obtained. 

Basophilic  granules  in  the  red  cells  may  be  found  in  severe  secondary 
anaemias  in  which  hemolysis  has  taken  place,  and  are,  on  the  other  hand, 
often  absent  in  cases  in  which  a  positive  diagnosis  of  lead  poisoning  can  be 
made.  In  looking  over  a  large  number  of  records  in  which  a  definite  diagnosis 
of  lead  poisoning  was  made  in  the  Out-patient  Department  of  the  Massa- 
chusetts General  Hospital,  by  the  clinical  symptoms  and  the  presence  of  the 
lead-line,  I  found  that  in  nearly  50  per  cent,  basophilic  granules  in  the  red 
cells  were  absent. 

Sir  Thomas  Oliver  states  that  in  only  a  few  instances  of  the  great  number  of 
examinations  of  the  blood  that  he  has  made,  in  early  as  well  as  in  late  cases 
of  plumbism,  has  he  found  the  basophihc  granules.  Basophilic  degeneration 
of  the  red  cells,  in  short,  does  not  possess  the  diagnostic  value  which  some 
attribute  to  it,  but  can  at  most  be  regarded  as  an  important  confirmatory 
sign.     Still  greater  importance  is  attached  to  the  presence  of  the  lead-line. 

In  my  investigation  of  some  of  the  lead  industries  of  Massachusetts 
for  the  State  Board  of  Health,  I  had  occasion  to  confer  with  many  physicians 
who,  from  time  to  time,  treated  patients  engaged  in  these  industries,  and  I 
frequently  found  that  no  matter  how  suggestive  the  symptoms  complained 
of  were  of  lead  poisoning,  the  diagnosis  was  not  made  because  of  the  absence 
of  the  lead-line.  As  a  matter  of  fact,  the  lead-line  presents  a  great  many 
anomahes,  and  irreparable  harm  will  often  be  done  when  a  diagnosis  of  plumb- 
ism is  not  made  because  of  its  absence.  In  the  investigation  referred  to 
above,  I  have  frequently  seen  well-marked  lead-lines  among  workers  exposed 
to  lead  who  did  not  present,  at  the  time  of  investigation  or  at  any  previous 
time,  any  signs  of  ill  health.  On  the  other  hand,  if  one  looks  into  the  very 
extensive  literature  on  the  subject,  one  will  find  many  cases  of  severe  lead 
poisoning  reported  in  which  lead  has  been  definitely  demonstrated  in  the 
urine  and  stools,  and  post-mortem  in  the  tissues,  and  yet  no  vestige  of  a  lead- 
line could  be  found.  Moreover,  the  lead-line  is  extremely  rare  when  the 
gums  are  in  a  healthy  condition  and  when  the  teeth  are  well  cared  for.  Dr. 
Oliver  fed  experimental  animals  with  lead  for  a  long  time  without  observing 
any  lead-line.  If,  however,  an  infection  of  the  gums  of  such  animals  was 
produced,  the  lead-line  appeared  within  a  short  time. 
7 


98  OCCUPATIONAL   INTOXICATIONS 

The  distinction  between  lead  absorption  and  lead  poisoning  is  not,  as  a 
rule,  clearly  borne  in  mind.  All  persons  working  in  lead,  unles§  the  most 
unusual  precautions  are  taken,  inhale. or  swallow  some  of  the  poison,  but  it  is 
excreted  through  the  kidneys  and  the  intestinal  tract,  or  is  stored  in  the 
body  tissues  as  an  insoluble  albuminate  of  lead.  If,  however,  for  some 
reason  metabolism  is  disturbed,  poisoning  is  the  result.  The  presence  of 
the  lead-line  simply  means  that  the  person  has  been  absorbing  lead,  and  is  in 
itself  of  no  greater  weight  in  the  diagnosis  of  lead  poisoning  than  is  the  fact  that 
the  patient's  history  shows  that  he  is  working  in  a  lead  process  in  which  we 
know  that  he  inevitably  absorbs  lead.  A  careful  inquiry  into  the  nature  of 
the  industrial  process  in  which  the  patient  is  engaged  is  therefore  of  the 
utmost  importance.  A  history  of  exposure  to  lead  justifies  the  diagnosis  of 
lead  poisoning  in  patients  presenting  obscure  symptoms  which  cannot  other- 
wise be  explained.  The  following  cases  seen  at  the  clinic  of  the  Massachusetts 
General  Hospital  illustrate  this  point: 

Case  I. — A  man  45  years  old  has  been  a  painter  for  24  years;  15  years  ago  he  is  said  to 
have  had  an  attack  of  abdominal  pain  which  lasted  for  2  weeks.  About  5  months  ago,  after 
a  short  period  of  idleness,  he  obtained  a  job  painting  the  inside  of  refrigerators.  He  worked 
for  only  2  weeks,  and  one  day  while  at  work  he  was  suddenly  attacked  with  blindness  and 
severe  abdominal  pain.  The  pain  lasted  2  days;  the  total  blindness  persisted  for  2  weeks 
and  then  he  began  to  improve  slowly.  At  the  time  of  the  examination  he  showed  a  low- 
grade  optic  neuritis  and  some  retinitis  of  both  eyes.  The  vision  of  the  right  eye  was 
one-half  and  of  the  left  eye  two-fifths  of  the  normal.  He  also  had  a  somewhat  contracted 
visual  field  for  both  form  and  color;  examination  otherwise  was  entirely  negative.  He 
showed  no  lead-line,  and  other  than  a  moderate  anaemia  his  blood  was  negative.  No 
stippled  cells  were  found.  At  the  time  of  the  onset  of  his  trouble  he  is  said  to  have  had  a 
very  marked  lead-line. 

The  history  of  exposure  to  lead  for  24  years,  and  the  attack  of  colic  15 
years'ago  which  lasted  2  weeks,  makes  it  certain  that  he  had  absorbed  a  con- 
siderable amount  of  lead  in  his  system.  The  work  in  refrigerators,  without 
any  ventilation,  in  all  probability  acted  as  a  predisposing  cause,  disturbing 
his  metabolism  and  thereby  precipitating  the  present  attack.  Even  if  no 
lead-line  had  been  observed  at  the  time  the  blindness  occurred,  in  the 
absence  of  lues  or  any  other  cause  for  the  optic  neuritis,  the  diagnosis  of 
lead  poisoning  is  perfectly  justifiable. 

* 

Case  2. — A  man  of  50,  a  painter  for  30  years,  is  said  to  have  had  "painter's  colic" 

12  years  ago  which  lasted  for  4  or  5  weeks.  Two  months  previous  to  his  present  illness  he 
had  to  sand-paper  old  paint  a  great  deal,  and  was  thus  exposed  more  than  usually  to  great 
quantities  of  dust.  About  3  weeks  previous  to  his  coming  to  the  clinic  he  felt  a  sudden 
stabbing  pain  in  the  left  elbow  which  lasted  only  for  a  few  minutes.  His  left  arm  then  began 
to  feel  stiff  and  weak,  and  he  had  a  continuous  dull  pain  in  the  elbow-joint.  Physical 
examination  was  entirely  negative  except  for  slight  weakness  of  the  flexor  muscles  of  the 
forearm.     There  was  no  lead-line  and  no  stippled  cells. 

In  this  case,  likewise,  the  history  of  long  exposure  and  the  absence  of 
any  other  condition  to  explain  the  symptoms  makes  a  diagnosis  of  lead 


EARLY   DIAGNOSIS    OF   LEAD   POISONING  99 

poisoning  justifiable;  a  subsequent  examination  revealed  the  presence  of  some 
stippled  cells. 

The  history  of  exposure  is  the  all-important  factor  in  the  diagnosis  of 
plumbism. 

In  cases  of  non-industrial  plumbism,  however,  in  which  no  history  of 
exposure  can  be  obtained,  the  presence  of  the  lead-hne  or  of  the  basophilic 
granules  is  of  inestimable  value  in  the  diagnosis,  since  it  offers  a  clue  for  the 
explanation  of  certain  symptoms  which  would  otherwise  be  obscure. 

The  following  case  reports  taken  from  the  records  of  the  Massachusetts 
General  Hospital  will  illustrate  the  reluctance,  even  among  good  clinicians, 
to  make  a  diagnosis  of  plumbism  in  the  absence  of  the  lead-line  or  stippling: 

Case  3. — A  man  of  36,  a  sheet-metal  worker  for  11  years,  handles  a  great  deal  of  lead  in 
his  work,  complains  of  pains  in  the  abdomen,  loss  of  weight,  weakness  of  extremities  and 
attacks  of  diarrhea  followed  by  constipation.     No  lead-line. 

Case  4. — A  man  of  34,  a  painter  for  10  years,  complains  of  attacks  of  colic,  headaches, 
obstinate  constipation  and  general  nervousness.     No  lead-line,  no  stippling. 

Case  5. — A  man  of  22,  a  painter  for  4  years,  complains  of  constipation,  attacks  of  severe 
abdominal  pains  and  headaches.     He  looks  pale;  no  lead-line,  no  stippling. 

Case  6. — A  painter  of  22,  who  has  worked  at  the  trade  for  10  years,  complains  of  obsti- 
nate constipation,  pain  in  his  joints,  headaches,  numbness  and  weakness  of  extremities;  he 
is  easUy  fatigued.     No  lead-line  or  stippling  found. 

Case  7. — A  worker  in  a  rubber  factory  for  6  years  complains  of  abdominal  pains,  obsti- 
nate constipation,  severe  pains  in  lumbar  region,  loss  of  appetite,  and  general  nervousness. 
No  lead-line  found. 

Case  8. — A  man  of  49,  a  painter  for  25  years,  gives  a  history  of  lead  poisoning  when  he 
first  started  his  work.  He  now  complains  of  tremor  and  weakness  of  hands  so  that  he  fre- 
quently drops  his  brush  while  at  work.  He  has  attacks  of  abdominal  pains,  pains  in  his 
joints,  and  is  pale.     No  lead-line  or  stippling  found. 

Case  9. — A  man  of  38,  who  worked  in  a  car  factory  for  14  years,  and  part  of  whose  work 
consisted  of  mixing  lead,  complains  of  sharp  pains  in  the  abdomen,  attacks  of  dizziness,  fine 
tremor  of  hands,  metallic  taste  in  the  mouth,  and  pains  in  the  extremities.  He  lost  con- 
siderable weight.     No  lead-line  or  stippling  found. 

In  none  of  the  foregoing  cases  was  a  definite  diagnosis  of  lead  poisoning 
made.  There  is  no  doubt,  however,  that  if  a  lead-line  was  present  in  any  of 
these  cases  or  if  stippled  red  cells  were  found,  even  if  the  symptoms  had 
been  less  characteristic,  a  positive  diagnosis  of  plumbism  would  have  been 
made.  Yet  the  occupation  of  these  patients  was  sufficient  evidence  that  lead 
absorption  was  taking  place,  and  the  symptoms  were  sufficiently  characteristic 
to  warrant  a  definite  diagnosis  without  the  corroborative  evidence  of  the 
lead-line  or  stippling. 

In  consequence  of  the  undue  weight  which  is  given  to  the  objective  signs, 
persons  who  show  themselves,  by  the  symptoms  of  which  they  complain, 
susceptible  to  the  influence  of  lead  are  permitted  to  continue  at  their  work 
without  any  additional  precautions  and  without  any  warning  as  to  the  danger 
to  which  they  are  exposed.  This  is  shown  by  the  following  illustrative  case 
reports,  taken  from  the  records  of  the  out-patient  department  of  the  Massa- 


lOO  OCCUPATIONAL   INTOXICATIONS 

chusetts  General  Hospital.  These  patients  attended  the  clinic  for  a  long 
time,  and  no  diagnosis  of  plumbism  was  made  because  of  the  absence  of 
the  lead-line  or  stippling.  At  some  later  date,  however,  although  the  symp- 
toms were  the  same,  the  diagnosis  of  plumbism  was  made  because  of  the 
appearance  of  one  or  the  other  of  these  objective  signs. 

Case  lo. — A  worker  in  a  rubber  factory  came  to  the  clinic  complaining  of  precordial 
pains,  headaches,  pains  in  the  arms  and  attacks  of  abdominal  pains.  He  had  evidence  of 
mitral  regurgitation.  There  was  no  lead-line,  and  no  diagnosis  of  lead  poisoning  was  made. 
He  came  again  8  months  later  with  the  same  symptoms  but  of  increased  severity.  A  lead- 
line was  found  present  at  this  time,  and  a  diagnosis  of  plumbism  was  made. 

Case  II.— A  painter  of  23  came  to  the  clinic,  November,  1907,  complaining  of  pain  in  the 
back,  numbness  and  weakness  of  extremities,  abdominal  pains,  headaches  and  nervousness. 
No  lead-line  was  present,  and  no  diagnosis  was  made.  In  191 2  he  presented  himself  with 
the  same  symptoms.  Lead-line  and  stippling  were  found,  and  a  diagnosis  of  lead  poisoning 
was  made. 

Case  12. — A  painter  presented  himself  at  the  clinic  in  July,  1907,  coi^plaining  of  con- 
stant severe  pain  in  the  upper  abdomen,  attacks  of  vomiting,  pains  in  the  knees  and  dizzi- 
ness. A  diagnosis  of  arteriosclerosis  was  made.  In  July,  1913,  he  presented  himself  again 
with  the  same  symptoms.  A  lead-line  and  stippling  were  found.  Diagnosis,  lead  poisoning. 

Case  13. — A  machinist  of  28  came  to  the  clinic  in  1906  complaining  of  attacks  of  severe 
abdominal  pains,  bad  taste  in  the  mouth,  obstinate  constipation,  attacks  of  nausea  and 
vomiting.  He  came  many  times  during  1910  and  again  in  1911,  complaining  of  the  same 
symptom-complex.  In  Decemben  1911,  a  lead-line  was  found  and  many  stippled  cells. 
Diagnosis  of  lead-poisoning  was  made. 

Case  14. — A  worker  in  a  rubber  factory,  aged  57,  came  in  1904  complaining  of  pain  in  the 
cardiac  area  and  in  the  right  shoulder,  pains  in  hips  and  legs,  weakness  of  extremities,  dizzy 
spells,  easily  tired  and  constipated,  also  wasting  of  extensor  muscles.  No  lead-line  was 
found  (patient  had  false  teeth).  No  diagnosis  of  lead  poisoning  was  made  until  1905,  when 
lead  was  found  in  the  urine. 

Case  15. — A  carriage  painter  of  38  came  in  1903  complaining  of  pains  in  the  back  be- 
tween the  shoulder  blades.  There  was  no  record  of  lead-line  or  stippling.  No  diagnosis 
was  made.  Later,  in  the  same  year,  he  came  complaining  of  attacks  of  dull  pain  in  the 
region  of  the  umbilicus,  and  sharp  pains  in  the  lumbar  region  which  kept  him  awake  for  2 
nights.  A  history  of  alcoholic  excess  was  obtained  for  the  last  2  weeks.  No  lead-line  was 
found.  Diagnosis,  alcoholism.  In  1908  he  came  again,  complaining  of  pains  in  his  back  and 
in  his  feet,  general  weakness  and  nervousness;  no  diagnosis  was  made.  Several  weeks 
later  he  came  again  complaining  of  the  same  symptoms. ,  A  lead-line  was  present  at  this 
time.     Diagnosis  of  lead  poisoning  was  made. 

The  unwarranted  delay  so  frequent  in  diagnosing  plumbism  even  in  the 
presence  of  a  definite  history  of  exposure  to  lead  is  well  illustrated  by  the 
last  case.  For  nearly  5  years  this  man  has  been  presenting  himself  at  va- 
rious times  at  the  hospital,  complaining  of  a  train  of  symptoms  which,  taken 
together  with  his  work,  should  have  made  a  diagnosis  possible,  and  yet  he 
was  permitted,  during  all  that  time,  to  continue  his  work  without  any  special 
precautions  until  the  lead-line  appeared,  when  the  diagnosis  of  lead  poisoning 
was  made. 

It  would,  of  course,  be  folly  to  attribute  to  lead  all  the  ill  health  of  lead 
workers.     The  symptoms,  therefore,  have  to  be  considered  carefully  before 


EARLY    DIAGNOSIS    OF    LE AD  •  PCISONINC  lOI 

the  responsibility  of  the  diseased  condition  is  laid  to  the  industry.  The  symp- 
toms of  early  plumbism  are  not  well  defined,  yet  there  is  a  group  of  symptoms 
which,  when  not  open  to  explanation  on  any  other  basis,  must,  when  a  history 
of  exposure  to  contact  with  lead  has  been  obtained,  be  taken  as  evidence  of 
early  lead  poisoning.  Indeed,  it  is  important  to  inquire  carefully  as  to  any 
possible  industrial  exposure  to  lead  whenever  certain  ill-defined  states  of  ill 
health  present  themselves  among  workers,  when  such  diagnosis,  for  instance, 
as  anaemia,  debility,  constipation,  lumbago  or  chronic  arthritis,  is  made. 
Inquiries  as  to  the  details  of  the  patient's  work  should  be  made,  for  unless 
the  physician  has  a  familiarity  with  the  various  industrial  processes,  the  gen- 
eral designation  of  the  patient's  work  may  not  indicate  any  exposure  to  lead. 
Pallor  of  the  skin,  muscular  weakness,  rheumatic  pains,  loss  of  appetite, 
constipation,  or  constipation  alternating  with  diarrhea,  abdominal  pains, 
general  nervousness,  and  persistent  headaches  should  always  be  regarded 
seriously  when  occurring  in  persons  exposed  to  lead,  for  they  may  be  the 
precursors  to  the  more  serious  nerve  lesions,  such  as  wrist-drop,  encephalo- 
pathy, and  to  the  more  insidious  and  less  dramatic  changes  in  the  vascular 
and  excretory  systems,  that  of  arteriosclerosis  and  chronic  nephritis. 


LEAD  POISONING  IN  THE  UNITED  STATES 

BY  ALICE  HAMILTON.  M.  D.,  Chicago.  lU. 

During  the  last  five  years  several  State  and  Federal  investigations  have 
been  made  to  determine  the  prevalence  of  industrial  lead  poisoning  in  the 
United  States.  These  investigations  do  not  lead  us  to  believe  that  lead  poi- 
soning is  a  slight  evil  in  our  country;  on  the  contrary  we  are  forced  to  ad- 
mit that  in  most  industries  our  rate  is  higher  than  the  German  or  British 
in  the  same  trades.  Our  methods  are  often  dangerous  and  our  factory 
sanitation,  though  in  some  places  excellent,  is  in  other  places  distinctly  bad. 
Nor  are  the  living  conditions  of  American  workmen  better,  their  food  more 
abundant,  their  housing  superior  to  those  of  British  or  German  workmen 
in  certain  lead  trades.  In  skilled  trades  such  as  painting,  plumbing,  print- 
ing, white  ware  glazing,  wages  are  high  and  the  men  Uve  well,  but  in  some  of 
the  most  dangerous  lead  trades,  the  making  of  white  lead  or  the  oxides, 
the  smelting  and  refining  of  lead,  the  making  of  storage  batteries,  the  paint- 
ing of  manufactured  goods,  the  employees  work  for  wages  which  are  below 
the  sum  required  for  a  family  to  maintain  what  is  called  an  American  stand- 
ard of  living. 

Lead  Poisoning  in  Illinois.' — This  is  a  fairly  typical  state  with  such  lead 
industries  as  smelting  and  refining,  the  manufacture  of  white  lead  and  the 
oxides,  paint  grinding,  sanitary  ware  enamelling,  tile  glazing,  Htho- 
transfer  works,  as  well  as  all  the  ordinary  industries  in  which  metallic  lead 
is  used.  The  inquiry  made  by  the  Commission  on  Occupational  Diseases 
covered  3  years,  1908  to  1910,  and,578  cases  of  lead  poisoning  were  found  to 
have  occurred  during  that  time,  308  of  them  in  the  last  year  and  chiefly  in  the 
city  of  Chicago.  They  were  scattered  through  about  70  occupations,  some 
of  which  had  never  been  supposed  by  Chicago  physicians  to  involve  risk  of 
lead  poisoning.  Among  the  less  famihar  ones  were:  the  making  of  car  seals, 
of  tin  foil,  the  wrapping  of  cigars  in  tin-foil,  laying  lead  coated  electric  cables, 
makiB^r  artificial  flowers,  handhng  wall  paper  colored  with  lead  pigments. 

Inquiry  showed  that  several  cases  which  were  reported  as  brass  poisoning 
were  really  lead  poisoning  and  that  the  brass  industry  in  Chicago  was  re- 
sponsible for  many  cases  of  plumbism.  Li tho- transfer  works  sent  several 
serious  cases  to  the  Cook  County  Hospital  and  owing  to  the  general  ignorance 
concerning  industrial  processes  some  of  these  were  not  recognized  at  first 
but  were  treated  as  appendicitis.  The  same  thing  was  true  of  another  in- 
dustry which  is  very  rarely  mentioned  in  the  literature  of  lead  posioning, 
the  work  of  the  commercial  artist  or  retoucher.  Several  cases  of  supposed 
zinc  poisoning  were  reported  to  the  Illinois  Commission,  the  victims  being 


LEAD   POISONING   IN   THE   UNITED    STATES  IO3 

commercial  artists  who  used  what  they  thought  was  a  zinc  paint  in  making 

sketches  for  catalogues  and  advertisements,  and  in  retouching  the  high  hght 
in  photographs  for  the  same  purpose.  Evidently  several  of  them  had  been 
treated  by  physicians  who  did  not  suspect  lead  poisoning,  but  the  supposedly 
zinc  white  paint  proved  to  be  white  lead  and  the  men's  habit  of  bringing 
their  brush  to  a  point  by  sucking  it  explains  the  poisoning,  as  does  also  the 
use  of  the  paint  in  the  form  of  a  very  fine  spray.  Fifteen  such  cases  were 
found  among  the  members  of  the  profession  in  Chicago. 

Another  unexpected  source  of  lead  poisoning  proved  to  be  the  zinc 
smelting  industry  in  La  Salle  County.  The  ore  contains  less  than  i  per  cent, 
of  lead,  it  is  said,  but  enough  is  volatilized  to  give  rise  to  plumbism  among 
the  smelters.  Tinsmiths,  makers  of  cofl&n  handles,  copper  and  nickel  buffers, 
sorters  in  junk  shops,  and  men  who  finish  cut  glass  by  rubbing  it  with  a 
lead  putty  powder,  were  others  of  the  miscellaneous  workers  who  made  up 
the  Illinois  lists. 

Sixty  Fatal  Cases  of  Industrial  Plumbism  in  New  York  State  in  1909  and 
1910.- — Histories  of  all  the  reported  deaths  from  industrial  plumbism  in 
New  York  State  during  the  years  1909  and  19 10  were  collected  and  published 
by  John  B.  Andrews.  Forty-five  of  the  60  cases  recorded,  or  75  per  cent., 
had  worked  with  wet  paint,  three  had  worked  at  lead  smelting,  four  in  the 
printing  trades,  three  in  white  lead  works,  two  in  storage  battery  plants, 
and  one  each  in  tinning,  in  making  rubber  balls  and  in  making  lead  pipe. 
As  would  be  expected,  nearly  all  of  them  were  chronic  cases,  of  several  years' 
duration.  Two  cases,  on  the  other  hand,  developed  fairly  rapidly.  One  of 
them,  a  painter,  had  worked  at  inside  painting  only  1 1  months  during  which 
time  he  had  had  cramps  in  his  stomach  during  several  months,  but  the  final 
attack  of  "gastro-enteritis  and  chronic  lead  poisoning"  lasted  only  2  days. 
The  other  was  a  boy  of  18  years  who,  some  17  months  before,  had  gone  to 
work  in  a  comparatively  safe  lead  trade,  the  making  of  tin  pails,  but  it  was 
carried  on  in  a  poorly  ventilated  shop.  At  the  end  of  6  months  he  felt  ill 
and  began  to  lose  weight,  at  the  end  of  the  year  he  was  forced  to  leave  work 
and  after  an  illness  of  10  weeks  died  of  "chronic  lead  poisoning." 

Among  the  more  unfamiliar  occupations  in  this  series  of  60  fatal  cases 
were:  The  making  of  rubber  toys  and  balls,  the  packing  of  machinery 
covered  with  wet  paint,  portrait  painting,  and  drawing-  bristles  through  the 
pads  of  brushes  which  had  been  painted  with  white  lead  paint. 

Lead  Poisoning  in  the  City  of  New  York.^ — A  survey  of  the  lead  trades  in 
the  city  of  New  York  and  a  report  on  cases  of  lead  poisoning  discovered  by  the 
investigators  and  occurring  during  1909,  1910,  and  191 1  was  made  by 
Edward  Ewing  Pratt  for  the  N.  Y.  State  Factory  Investigating  Committee. 
The  report  includes  a  detailed  description  of  some  of  the  more  important 
industries:  The  manufacture  of  white  lead  and  red  lead,  the  making  of  paints, 
the  use  of  lead  as  a  hardening  and  tempering  agent.  This  last,  an  occupa- 
tion hardly  mentioned  in  most  of  the  works  on  lead  poisoning.  Dr.  Pratt 


I04  OCCUPATIONAL   INTOXICATIONS 

found  to  be  very  dangerous.  He  traced  no  less  than  nine  cases  of  lead 
poisoning  to  one  factory  which  had  been  in  operation  only  i  year  and  in 
which  the  regular  force  employed  was  only  nine  men.  The  work  involves 
hardening  steel  magnets  in  a  bath  of  molten  lead  the  temperature  of  which  in 
this  case  was  from  1400°  to  i8oo°F.  Here  they  remain  till  red  hot,  when  a 
workman  takes  them  out  and  plunges  them  into  a  barrel  of  water  to  cool. 
Then  they  are  stacked  about  an  upright  bar  and  rubbed  with  sandpaper  to 
remove  adhering  bits  of  lead.  In  addition  to  the  risk  from  fumes  and  from 
the  lead  dust  caused  by  the  rubbing  there  is  dust  from  the  oxide  which  forms 
on  the  surface  of  the  molten  kad  and  is  skimmed  off  and  thrown  on  the  floor. 
A  similar  process  was  seen  in  a  factory  where  piano  wires  and  springs  are 
made. 

Lead  was  found  to  be  used  in  the  making  of  linoleum  and  oilcloth,  first 
as  a  drier  added,  in  the  form  of  litharge,  to  boiling  oil,  second  in  the  paints 
which  consist  largely  of  lead  colors.  Six  cases  of  lead  poisoning  were 
on  record  in  the  hospital  nearest  to  the  village  in  which  the  factory  is 
situated. 

Dr.  Pratt  studied  109  of  the  376  cases  discovered  by  his  investigators. 
Of  these,  six  were  fatal,  20  had  wrist-drop,  18  paralysis  of  other  limbs,  54 
incipient  paralysis,  and  two  encephalopathy.  The  painting  trade  was  most 
largely  represented,  with  42  cases,  then  came  white  lead  with  23,  and  then 
work  with  solder  and  other  metallic  lead.  Among  the  less  usual  sources  of 
lead  poisoning  in  this  list  are  such  industries  as  stamping  designs  on  embroid- 
ery with  a  mixture  of  rosin  and  white  lead;  chipping  old  red  lead  paint  from 
the  hold  in  a  battleship;  polishing  diamonds,  the  diamond  being  embedded 
in  a  pear-shaped  lump  of  lead  and  held  against  a  revolving  disc,  which  at 
the  same  time  grinds  off  part  of  the  lead. 

Very  interesting  and  valuable  tests  to  determine  the  presence  of  lead  in 
the  air  surrounding  lead  pots,  casting  machines,  soldering  benches,  etc.,  are 
described  by  C.  T.  Graham  Rogers  and  John  H.  Vogt.'*  The  results  are  of 
great  value  in  settling  the  question,  which  is  still  in  dispute  as  to  whether  or 
not  lead  fumes  are  given  off  under  certain  circumstances.  For  instance, 
when  I  was  investigating  storage  battery  plants,  I  was  always  assured  that 
there  could  be  no  danger  from  the  casting,  because  the  lead  in  the  kettles  was 
below  the  fuming  point.  I  found  cases  of  lead  poisoning  nevertheless  among 
moulders  and  the  explanation  is  furnished  by  the  tests  of  air  in  two  casting 
rooms  made  by  Rogers  and  Vogt.  They  found  in  i  cubic  meter  of  the  air  of 
a  casting  room  3.4  mg.  of  lead,  and  in  another  factory  where  the  kettles  are 
covered  with  hoods  i.o  mg.  As  an  adult  breathes  about  4.5  cubic  meters  in 
the  course  of  10  hours,  this  means  that  it  would  be  possible  for  a  man  in  the 
first  factory  to  breathe  15.3  mg.  during  one  working  day  and  for  a  man  in 
the  second,  4.5  mg.  provided  this  contamination  of  the  air  were  constant. 
Another  striking  report  on  the  amount  of  lead  in  the  air  is  found  in  the 
description  of  a  factory  making  dairy  implements.     A  number  of  cases  of 


LEAD    POISOXIXG    IX    THE    UXITED    STATES  I05 

lead  poisoning  had  been  reported  among  the  men  engaged  in  making  cream 
separators,  and  when  a  visit  was  made  to  the  plant  it  was  discovered  that 
during  the  finishing  process  a  putty  consisting  of  65  per  cent,  lead  was  put  on 
the  metal  part,  baked  in  an  oven  and  when  hard,  sandpapered.  An  analysis 
of  the  air  in  the  room,  which  was  large  and  well  ventilated,  showed  no  lead 
but  a  sample  taken  at  the  breathing  level  of  a  worker  while  sandpapering 
showed  68.8  mg.  of  lead  per  cubic  liter  of  air,  clearly  proving  that  the 
danger  came  from  inhaling  the  dust  laden  air  during  the  process  of  sand- 
papering. 

A  man  in  a  factory  where  brass  nozzles  are  caulked  into  hydrants  by  means 
of  molten  lead  was  heating  his  lunch  at  the  lead  pot.  The  air  near  this  pot 
at  the  breathing  level  had  5  mg.  of  lead  in  i  cubic  meter. 

Some  negative  results  also  in  this  inquiry  are  interesting.  We  read 
in  foreign  works  about  lead  poisoning  in  the  making  of  glass,  in  dyeing, 
in  the  manufacture  of  shoes,  in  harness  making  and  in  polishing  precious 
stones.  Rogers  and  Vogt  found  only  two  out  of  six  glass  factories  using 
lead,  but  in  those  two,  dust  is  allowed  to  escape  and  the  air  of  the  mixing 
rooms  is  badly  contaminated  with  lead.  In  other  industries,  dyeing, 
shoemaking,  etc.,  there  was  found  to  be  no  danger  from  this  source. 
On  the  other  hand,  the  mixing  of  ingredients  for  rubber  (lead  oxide  and 
lead  chromate  are  used)  was  found  to  be  attended  with  danger,  as  no 
precautions  are  taken  to  protect  the  weighers  and  mixers  from  dust.  A 
sample  of  air  taken  in  a  mixing  room  during  the  process  of  filling  the  mixer 
yielded  8  mg.  of  lead  per  cubic  meter. 

These  writers  advise  that  special  rules  be  passed  by  the  State  for  the 
following  industries:  ]\Ianufacture  of  white  lead;  of  dry  colors;  of  lead  oxides; 
of  paint  and  varnish;  of  storage  batteries;  potteries;  smelting,  making  of 
alloys  and  plumbers'  supplies;  manufacture  of  articles  from  metallic  lead; 
manufacture  of  rubber  goods  where  lead  is  used;  painting  of  manufactured 
articles. 

The  inquiries  carried  on  by  the  Bureau  of  Labor  of  the  Federal  Govern- 
ment and  more  recently  by  the  Bureau  of  Labor  Statistics  of  the  Department 
of  Labor, ^  have  concerned  individual  industries  and  the  method  has  been  to 
make  an  intensive  study  of  the  establishments  in  which  the  work  is  done  and 
to  collect  all  the  available  information  about  lead  poisoning  in  each  one.  This 
information  is  always  far  from  complete.  There  are  now  many  states  which 
require  that  all  cases  of  industrial  lead  poisoning  be  reported  to  some  central 
office,  but  most  of  them  have  passed  such  a  law  only  recently  and  have  as  yet 
no  really  trustworthy  statistics.  Moreover  American  physicians  are  not  yet 
convinced  of  the  necessity  of  this  legislation  and  the  majority  do  not  take  the 
trouble  to  send  in  reports  of  any  but  the  severer  cases,  while  some  who  are 
employed  as  company  physicians  feel  that  they  are  bound  in  loyalty  to  their 
employers  to  keep  secret  the  number  of  cases  of  plumbism  which  occur  in 
the  plant.     I  have  myself  seen  a  bill  presented  by  a  doctor  to  the  company 


Io6  OCCUPATIONAL  INTOXICATIONS 

asking  pay  for  the  treatment  of  57  cases  of  acute  lead  poisoning,  while  his 
report  to  the  State  put  the  number  at  27  only. 

This  makes  it  impossible  in  all  but  a  few  instances  to  know  exactly  how 
much  lead  poisoning  there  is  in  any  of  the  lead  trades  in  the  United  States 
and  the  cases  discovered  in  the  course  of  these  inquiries  always  fall  below  the 
truth.  This  was  especially  true  of  the  first  investigation,  that  of  the  white 
lead  and  lead  oxide  industries,  for  at  that  time  the  subject  of  lead  poisoning 
among  working  people  had  attracted  little  attention  and  there  were  many 
employers  who  were  genuinely  ignorant  of  the  extent  of  the  evil  in  their  own 
establishments.  The  only  study  I  have  been  able  to  find  in  American  medical 
literature  of  industrial  lead  poisoning  among  white  lead  workers  is  an  article  by 
Wm.  R.  Hobbs,^  written  in  1898.  He  reports  42  cases  from  one  white  lead 
works,  all  but  eight  of  them  severe  in  type.  Two  had  epileptiform  attacks, 
one  was  a  case  of  acute  meningitis,  lasting  2  weeks  and  ending  in  recovery,  a 
fourth  had  complete  paralysis  of  biceps  and  deltoids,  dilated  heart  with  mitral 
regurgitation,  parenchymatous  nephritis,  later  on,  insomnia,  loss  of  memory, 
listlessness,  oedema,  anasarca  and  death.  Some  of  Hobbs'  cases  developed 
after  only  a  few  weeks'  exposure,  and  no  less  than  35  of  the  42  after  less  than 
a  year's  exposure. 

Manufacture  of  White  Lead,  Litharge,  Orange  Mineral,  and  Red  Lead.^ — 
The  white  and  red  lead  industry  is  carried  on  in  Brooklyn  and  Staten  Island, 
N.  Y.  I  Camden  and  Perth  Amboy,  N.  J. ;  Philadelphia,  Pittsburgh  and  Ken- 
sington, Pa.;  Cincinnati,  O.;  Chicago,  111.;  St.  Louis,  Mo.  and  Joplin,  Mo.; 
Omaha,  Neb. 

There  are  also  two  establishments  on  the  Pacific  coast  but  these  were  not 
included  in  this  investigation.  The  regular  pay  roll  of  the  23  factories  east 
of  California  was  in  1911  about  1600  men,  but  a  much  larger  number  than 
that  was  employed  during  a  year's  time,  for  the  superintendents  all  admitted 
that  the  force  was  very  shifting.  In  one  establishment  250  men  had  been 
hired  during  6  months  in  order  to  keep  up  a  force  of  only  58  men. 

The  processes  used  in  making  white  lead  in  the  United  States  are  four,  the 
Old  Dutch,  the  Carter,  the  Matheson  and  the  Mild,  but  the  first  is  the  most 
usual  and  the  last  two  are  used  in  only  one  factory  each.  For  the  Old  Dutch 
process,  the  lead  is  cast  in  thin  discs  and  these  are  packed  in  pots  with  acetic 
acid  and  buried  in  old  tan  bark  for  about  100  days,  when  the  metallic  or 
"blue"  lead  is  found  to  have  "corroded,"  that  is,  changed  to  white  lead,  the 
basic  carbonate.  In  removing  this  white  lead  ("stripping  the  white  beds") 
there  is  a  great  deal  of  dust  and  the  men  cannot  sprinkle  it  with  water  as  is 
done  in  England  and  Germany,  because  in  our  factories  the  products  of  the 
corrosion  must  go  through  a  series  of  grinders  and  screens  to  separate  the 
white  lead  from  the  unchanged  metal  in  the  center  of  the  disc,  and  damp- 
ness would  result  in  clogging  the  screens.  In  the  factories  I  have  visited  in 
England  and  Germany  this  separation  is  done  by  washing  the  corroded  lead 
off  in  great  troughs  of  running  water.     A  Belgian  factory,  near  Brussels,  had 


LEAD    POISONING    IX    THE    UNITED    STATES  IO7 

a  process  similar  to  the  American.  This  use  of  dry  instead  of  wet  separation 
increases  very  much  the  difficulty  of  making  American  factories  dust-free, 
and  at  the  time  this  investigation  was  made  the  work  of  "stripping"  was  pro- 
ductive of  a  great  deal  of  poisoning.  Since  then,  however,  I  have  seen  in 
three  plants  an  excellent  protective  device,  a  truck  with  a  cover  which  has  an 
opening  just  large  enough  to  allow  the  pot  of  white  lead  to  be  emptied  in. 
Another  opening  is  for  a  large  exhaust  pipe  which  carries  oS  the  dust  formed  by 
the  falling  of  the  contents  of  the  pot.  This  exhaust  pipe  is  flexible  and  long 
so  that  the  truck  can  be  moved  about  without  disturbing  the  mechanism. 

The  second  danger  spot  in  a  white  lead  establishment  is  the  dry  pan 
room,  where  the  white  lead  after  repeated  washings  is  pumped  into  great  hot 
pans  and  left  to  dry,  when  it  is  emptied  into  trucks  and  taken  to  the  packers 
or  to  be  ground  in  oil.  In  most  establishments  visited,  a  certain  amount  of 
white  lead  was  ground  as  "pulp  lead,"  the  oil  displacing  the  water  without 
any  drying  process.  Work  as  conducted  in  dry  pan  rooms  was  dangerous 
work  when  first  investigated.  I  remember  seeing  two  men  in  a  low,  hot  pan 
room,  standing  on  the  dry  white  lead  in  the  pan  and  shovelling  it  to  the  edge, 
then  throwing  it  into  a  truck  below  as  carelessly  as  if  it  were  so  much  sand. 
Since  then,  however,  this  work  has  been  much  improved  in  the  better  facto- 
ries, the  pans  entirely  enclosed,  connected  with  the  exhaust  system,  and  the 
dry  lead  emptied  into  a  screw  conveyor  which  is  placed  inside  the  enclosing 
jacket,  so  that  the  dust  raised  by  the  shovelling  does  not  escape  but  is  drawn 
in  by  the  suction  of  the  exhaust. 

In  the  Carter  process,  the  dust  problem  is  a  serious  one,  for  this  is  a  quick 
corrosion  of  lead  which  has  been  reduced  to  the  finest  powder,  so  that  from 
start  to  finish  the  men  are  handling  powdered  material.  The  advantage  of 
the  method  is  that  it  requires  a  small  force  of  workmen  and  the  modifications 
made  from  year  to  year  tend  to  lessen  still  further  the  amount  of  hand-work. 

The  Matheson  process  is  a  precipitation  process  and  safer  than  the  Old 
Dutch,  because  work  in  the  corroding  stacks  is  replaced  by  precipitation  of 
white  lead  in  water.  The  Mild  is  also  a  wet  process,  atomized  lead  being 
exposed  to  air  and  carbon  dioxide  and  water  in  large  cylinders.  However 
in  both  these  factories  the  drying  and  grinding  and  packing  of  the  finished 
product  is  as  dangerous  as  in  an  Old  Dutch  establishment. 

The  roasting  of  lead  oxides  is  not  carried  on  in  connection  with  lead  smelt- 
ing in  the  United  States  as  it  is  in  most  other  countries,  with  the  exception 
of  one  smelting  plant.  It  is  done  either  separately  or  in  connection  with  the 
making  of  white  lead.  The  dangers  in  this  work  consist  in  the  fumes  from 
the  furnaces,  and  in  the  dust  from  dumping,  grinding,  screening,  and  packing 
the  oxides.  I  have  seen  some  red  lead  factories  in  this  country  which  were 
so  free  from  dust  that  one  would  not  guess  from  their  appearance  that  colored 
materials  were  made  there.  Mechanical  furnaces,  well  hooded,  have  done 
away  with  fumes,  exhausts  over  the  dumps  and  closely  covered  grinders  and 
screens  have  prevented  the  escape  of  dust.     In  such  plants  the  danger  of 


I08  OCCUPATIONAL    INTOXICATIONS 

lead  poisoning  is  slight,  but  in  a  poorly  managed  oxide  works,  with  much 
hand-work,  the  danger  may  be  even  greater  than  in  the  white  lead  depart- 
ment. In  one  factory  I  found  that  during  the  preceding  i6  months  there 
had  been  14  cases  of  lead  poisoning  among  65  white  lead  men  making  a  rate 
of  22.5  per  hundred,  and  7  among  12  red  lead  men,  or  58.3  per  hundred. 
The  average  period  of  employment  was  4  years  for  the  white  lead  men  and 
only  I  year  for  the  red  lead  men.  It  is  partly  the  great  fluffiness  and  light- 
ness of  the  oxides,  especially  litharge,  which  makes  them  so  dangerous,  for 
their  solubility  in  human  gastric  juice  is  less  than  that  of  the  basic  carbonate. 

The  number  of  cases  of  lead  poisoning  found  in  these  two  industries  in 
191 1  was  388,  occurring  during  16  months'  time  in  factories  with  a  pay  roll 
of  1600  men.  Neither  of  these  figures  is  accurate.  More  men  than  1600 
were  employed  in  these  plants  during  that  time,  and  more  than  388  cases  of 
lead  poisoning  undoubtedly  occurred,  for  this  number  represents  only  those 
who  could  be  traced  by  investigators  working  against  great  difficulties. 
The  fatal  cases  numbered  16.  The  period  of  exposure  before  poisoning 
occurred  was  usually  short,  89  out  of  120  falling  ill  after  less  than  a  year's 
work.  Undoubtedly  there  is  less  lead  poisoning  now  in  this  industry  than 
at  that  time,  for,  in  addition  to  the  many  improvements  w^hich  have  been 
made  in  the  factories,  physicians  have  been  employed  to  examine  and  treat 
the  men,  but  the  falling  off  in  the  sickness  rate  cannot  be  statistically  proven, 
since  these  physicians,  if  they  report  cases  of  lead  poisoning  at  all,  report  only 
the  severer  ones. 

Glazing  and  Decorating  White  Ware  and  Sanitary  Earthenware  and 
Tiles.^ — The  pottery  industry  in  the  United  States  is  carried  on  chiefly  in 
two  districts,  the  region  around  East  Liverpool,  Ohio,  which  includes  towns 
in  West  Virginia,  and  in  and  about  Trenton,  N.  J.  White  ware  includes  table 
and  toilet  ware;  sanitary  earthenware  includes  tubs,  basins,  closets,  sinks, 
etc.,  which  are  made  of  glazed  clay,  in  distinction  from  porcelain  enamelled 
iron  ware. 

In  these  potteries  there  are  about  a  thousand  persons  employed  in  work 
which  involves  exposure  to  lead  in  some  form,  only  150  of  them  being  women. 
No  leadless  glaze  is  used,  except  on  the  very  large  ware,  the  bath  tubs,  laun- 
dry tubs  and  sitz  baths,  which  are  covered  with  a  leadless  glaze  and  subjected 
to  one  prolonged  firing  that  at  once  biscuits  the  clay  and  fuses  the  glaze. 
Smaller  pieces,  closets,  wash-basins,  and  all  table  and  toilet  ware,  are  first 
fired  to  biscuit  the  clay  and  then  covered  with  a  lead  glaze  and  fired  again. 
The  glazes  used  in  the  30  table  and  toilet  ware  potteries  investigated  con- 
tained lead  in  proportions  ranging  from  5  per  cent,  to  20  per  cent.,  but  in 
only  seven  was  it  as  low  as  5  per  cent.;  in  the  other  23,  the  lead  was  from  15 
per  cent,  to  20  per  cent.  For  sanitary  ware  less  lead  is  used,  seven  out  of 
nine  potteries  using  a  glaze  with  less  than  15  per  cent.  lead.  White  lead  is 
the  compound  almost  always  used. 

In  England  and  on  the  Continent  there  has  been  for  many  years  a  strong 


LEAD    POISONING    IN    THE    UNITED    STATES  I09 

movement  in  favor  of  insisting  on  the  use  of  "fritted"  glazes.  In  fritting, 
the  lead  is  added  at  the  beginning  to  the  other  glaze-forming  constituents 
and  is  fused  with  them,  in  the  course  of  which  a  large  part  of  it  is  changed 
from  a  soluble  to  an  insoluble  form,  the  disilicate.  The  statement  has 
frequently  been  made  to  me  in  American  potteries  that  the  glaze  in  use  has 
all  been  fritted,  but  unfortunately  it  is  the  American  custom  to  add  part,  if 
not  all,  of  the  lead  after  fritting. 

The  occupations  which  expose  pottery  workers  to  the  danger  of  lead 
poisoning  have  to  do  with  the  glaze  and  with  the  lead  colors  used  in  decora- 
ting. Mixing  the  glaze  is  done  by  laborers  under  the  direction  of  a  skilled 
foreman.  Dipping  the  ware  in  liquid  glaze  is  skilled  work  and  is  always 
done  by  men,  as  is  also  the  stacking  of  the  dipped  ware  in  the  kilns  for  firing. 
The  dippers'  helpers,  who  clean  the  excess  of  glaze  from  the  ware,  are  unskilled 
women  or  boys,  or  in  sanitary  ware  potteries  where  the  ware  is  very  heavy, 
young  men.  Decorating  is  skilled  work  and  employs  both  men  and  women. 
Most  ware  in  this  country  is  now  decorated  by  means  of  litho-transfer  paper, 
which  is  entirely  devoid  of  danger,  but  there  is  still  some  color  blowing  and 
hand  decoration,  though  chiefly  in  art  pottery,  not  white  ware. 

In  none  of  the  potteries  visited  were  proper  washing  facilities  provided 
for  the  people  exposed  to  lead,  nor  lunch  rooms,  nor  working  clothes,  nor  was 
there  any  evidence  of  an  effort  on  the  part  of  the  management  to  protect 
the  work-people  from  lead  poisoning.  Even  in  newly  erected  potteries  the 
floor  of  the  dipping  room  was  always  of  wood  and  dry  sweeping  was  very 
common.  I  saw  the  dippers'  helpers  in  several  places  prepare  for  lunch  by 
rinsing  their  hands  in  a  pail  of  water  which  the  dippers  had  already  used, 
and  then  sit  down  and  open  their  dinner  pails  in  that  very  room.  They  say 
that  in  the  2  years  that  have  elasped  since  this  investigation  was  made  much 
has  been  done  to  improve  conditions  in  the  industry,  but  very  radical  changes 
in  construction  and  management  would  be  needed  to  bring  our  potteries  up 
to  the  British  standard. 

White  ware  potters  are  an  intelligent  class  of  workmen  with  a  strong 
trade  union,  good  wages,  and  short  hours.  There  are,  however,  in  these  same 
potteries  laborers  and  boys  and  women  and  girls  who  earn  low  wages  and 
do  not  have  any  of  the  advantages  of  organization.  It  was  among  these 
last  that  the  highest  rate  of  lead  poisoning  was  found.  Even  among  the 
dippers  and  kilnmen  the  rate  was  high.  One  dipper's  local  of  85  men  had 
had  in  i  year  13  cases  of  lead  poisoning,  as  many  as  there  were  among 
786  English  male  dippers,  making  a  rate  for  our  dippers  of  one  in  six  or  seven 
and  for  the  Staffordshire  dippers  of  one  in  60  or  61.  Though  it  is  a  skilled 
and  well-paid  trade  119  dippers  averaged  only  from  17  to  18  years  employ- 
ment and  200  glost-kilnmen  only  14)2  years.  As  for  the  dippers'  helpers, 
the  rate  of  lead  poisoning  among  them  was  found  to  be  13  in  180  in  Trenton, 
where  men  and  boys  are  employed,  and  29  among  150  in  Ohio,  where  women 
are  employed.     This  greater  incidence  among  women  is  always  noted  by 


no  OCCUPATIONAL   INTOXICATIONS 

English  authorities,  especially  by  Oliver.  Comparing  the  dippers  in  East 
Liverpool  with  their  women  helpers  we  find  the  men's  rate  to  be  17  per  100 
employed,  the  women's  33  per  100,  almost  double. 

Art  and  Utility  Ware. — This  term  covers  the  yellow  earthenware  used  in 
kitchens,  the  dark  brown  teapots  known  as  Rockingham  ware,  and  majoUca 
or  decorated  ware  of  all  kinds,  vases,  pedestals,  umbrella  stands,  spittoons, 
etc.  All  these  are  made  with  a  glaze  rich  in  lead,  containing  from  20  per 
cent,  up  to  50  per  cent.  In  these  potteries  there  is  much  more  mixing  of 
glaze  and  much  more  decorating  than  in  the  white  ware.  Decorating  is  done 
partly  by  hand  painting  partly  by  spraying  on  the  colors  by  means  of  an 
atomizer  and  a  stream  of  compressed  air.  This  is  the  process  which  in 
British  reports  is  spoken  of  as  "color  blowing,"  and  regarded  as  requiring 
special  safeguards.  The  ware  is  held  under  a  hood  furnished  with  an  air 
exhaust  and  if  the  draft  is  strong  enough,  the  spray  not  driven  with  too  much 
force,  and  the  hood  deep  enough,  and  the  decorator's  sight  good  enough  so  that 
he  can  hold  the  ware  at  a  distance  from  his  face,  the  work  is  not  dangerous, 
but  in  many  American  potteries  these  conditions  are  not  found.  Poor  hoods 
and  feeble  exhausts  were  found  to  be  quite  common. 

The  workers  in  this  class  of  potteries  are  exposed  to  greater  dangers  than 
those  in  white  ware,  because  the  glaze  is  richer  in  lead  and  because  more  color 
blowing  is  done,  and  in  addition  it  was  found  that  the  standard  of  cleanliness 
is  even  lower  in  these  potteries  than  in  the  white  ware  branch,  so  that  the 
exposure  to  lead  dust  is  greater.  Another  great  disadvantage  in  this  branch 
of  pottery  work  is  the  fact  that  it  is  entirely  unorganized  and  consequently 
wages  are  low  and  the  proportion  of  women  employees  is  much  higher.  The 
influence  of  all  these  factors  can  be  seen  in  the  following  table  which  gives  the 
rate  of  lead  poisoning  among  the  white  ware  potters  and  that  among  the  art 
and  utility  ware  potters.     The  men  only  are  included. 

While  ware: 

No.  employed,  796.     Cases  in  2  years,  60.     Rate  per  100,  7.5. 

Art  and  Utility  Ware  and  Tiles: 

No.  employed,  304.     Cases  in  2  years^63.     Rate  per  100,  27. 

Tiles. — The  glazing  and  decorating  of  tiles  is  carried  on  in  the  same  dis- 
trict as  the  making  of  art  pottery,  the  region  around  Zanesville,  O.,  and  as  it  is 
also  a  dangerous  and  insanitary  and  underpaid  industry  it  was  found  impos- 
sible to  separate  the  cases  contracted  in  the  potteries  in  this  district  from 
those  contracted  in  tile  works  and  the  two  industries  had  to  be  studied  to- 
gether, though  in  many  ways  the  work  in  a  tile  factory  is  different  from  that  in 
a  pottery.  Aside  from  the  Zanesville  region,  tile  factories  were  found  in 
Trenton,  N.  J.;  Newell,  W.  Va.;  Covington  and  Newport,  Ky.;  IndianapoHs, 
Ind. ;  Chicago  Heights,  111. ;  and  Morristown,  Pa.  The  glazes  in  these  plants 
contain  as  little  lead  as  5  per  cent.,  in  the  case  of  white  glaze,  and  as  much  as 
50  per  cent,  or  even  60  per  cent.,  in  colored  glazes.     The  lowest  quantity, 


LEAD   POISONING   IN   THE   UNITED    STATES  III 

5  per  cent,  was  found  in  only  two  factories;  in  all  the  others  the  lead  content 
ran  from  20  per  cent.  up.  White  glaze  is  applied  by  machinery  in  some  fac- 
tories, but  colored  tiles  are  glazed  by  dipping  or  by  pouring  on  the  glaze, 
or  in  the  case  of  mottled  ''onyx"  tiles,  by  scattering  it  from  a  pail  by 
hand. 

Scraping  ofif  the  excess  of  glaze,  or  "fettling"  as  it  is  called,  is  more  danger- 
ous than  actual  glazing  because  it  is  dustier.  In  all  English  tile  works,  and 
in  many  German,  it  is  the  rule  to  scrape  the  excess  glaze  while  it  is  damp  and 
let  it  fall  into  a  pan  of  water.  In  all  the  tile  works  I  have  visited  in  this  coun- 
try, much  of  the  fettling,  if  not  all,  is  done  dry  and  the  glaze  dust  allowed  to 
fall  anywhere.  I  have  even  seen  girls  brush  off  glaze  with  a  stiff  brush,  and 
then  blow  the  tile  clean.  Nowhere  have  I  seen  any  apparent  recognition  of 
the  danger  of  this  work. 

The  rate  of  lead  poisoning  among  men  and  women  in  these  two  branches 
is  given  in  the  following  table.  It  will  be  noticed  that  here  where  there  is  no 
advantage  on  the  part  of  the  men,  where  all  earn  low  wages,  the  men  have  a 
somewhat  higher  rate  than  the  women,  but  then  they  remain  longer  in  the 
industry  than  most  of  the  women  do. 

Males,         No.  employed,  304.     Cases  of  plumbism  in  i  year,  48.     Rate  per  100,  15.  i 
Females.     No.  employed,  243.     Cases  of  plumbism  in  i  year,  28.     Rate  per  100,  11. 5 

The  fuU  effect  of  the  neglect  of  all  hygienic  precautions  in  this  industry 
can  be  seen  if  we  compare  our  record  for  i  year  with  a  year's  record  in  British 
potteries,  which  are  better  managed  than  any  I  have  visited  in  other  countries. 
This  table  shows  the  contrast. 

Frequency  of  Lead  Poisoning  in  each  Sex,  in  all  Potteries,  Great  Britain,  19 10, 
AND  IN  Potteries  Visited,  United  States,  19 ii 

,        All  potteries.  Great  Britain        I  Potteries  visited,  United  States, 

1911 


Sex  I  Cases  of  L,!if'?il^' 

Employees       lead      !  cases  oflead 

in  1907        poison-     P°f°^'fSA°  ^'^Pl°y««^ 
-^.^^-,    employees'    I 


Cases  of 
lead 

poison- 
ing 


Ratio  of 

cases  of  lead 

poisoning  to 

number  of 

employees 


Males 4504      !       40      I    I  to  113         iioo  87      i  to  12  or  13 

Females 2361  37  i  to    64  393  57     j      i  to  7 


Total I     6865  77  I  to    89         1493  144       I  to  ID  or  II 

Porcelain  Enamelled  Sanitary  Ware.^ — The  very  heavy,  solid  bath  tubs 
which  are  found  in  large  houses  and  in  hotels  are  made  of  earthenware  and 
covered  with  a  leadless  glaze,  but  the  ordinary  bath  tubs  which  give  a  metaUic 
sound  when  struck,  are  made  of  iron  and  covered  with  a  lead  glaze  applied 
in  the  form  of  powder  over  the  red  hot  surface.  Wash-basins  and  kitchen 
sinks  are  enamelled  in  the  same  way. 


112  OCCUPATIONAL   INTOXICATIONS 

This  is  a  large  and  important  industry  in  the  United  States.  In  the  lo 
factories  visited,  which  include  the  five  largest,  a  little  over  looo  men  are 
employed  in  work  which  exposes  them  to  lead.  These  factories  are  in 
Chicago;  Sheboygan,  Wis.;  Louisville,  Ky.;  Chattanooga,  Tenn.;  Salem, 
Ohio;  Trenton,  N.  J.  and  in  Pittsburgh  and  three  towns  in  the  vicinity.  The 
thousand  men  are  employed  in  mixing,  grinding  and  sifting  enamel,  and  in 
applying  it  to  the  ware. 

The  cast-iron  bath  tubs,  sinks  and  basins  are  first  roughened  by  a  sand 
blast  and  then  placed  by  the  enamellers  in  a  furnace,  heated  red  hot,  brought 
out  and  sprinkled  thickly  with  a  powder  which  is  essentially  a  ground  glass 
containing  soluble  lead.  Seven  samples  of  enamel  were  subjected  to  the 
Thorpe  test  and  were  found  to  contain  soluble  lead  in  the  following  quantities: 
0.51  per  cent.,  2.55  per  cent.,  6.31  per  cent.,  8.35  per  cent.,  9.04  per  cent., 
10.22  per  cent,  and  20.4  per  cent.  The  lead  used  for  making  this  enamel  is 
red  lead  or  litharge,  and  the  mixture  is  always  fritted,  yet  soluble  lead  is 
there. 

The  men  who  mix  and  grind  are  exposed  to  dust,  the  men  who  enamel  are 
also  exposed  to  dust  and  to  great  heat  and  to  fatigue  from  the  exertion  of 
handling  the  heavy  pieces.  It  is  a  very  dangerous  trade  and  the  amount  of 
lead  poisoning  is  great,  yet  even  in  the  best  factories  little  is  done  to  protect 
the  men  and  in  the  worst,  conditions  are  very  bad.  The  enamellers  are  well 
paid,  for  it  is  work  requiring  skill,  but  250  men  whom  I  interviewed  had 
averaged  only  6  years  in  the  trade.  Mixers  who  are  paid  day  laborers' 
wages  are  still  more  shifting. 

Two  hundred  and  seventeen  cases  of  lead  poisoning  were  found  to  have 
occurred  among  1012  men  during  1911,  which  would  give  a  rate  of  21.4  per 
100  employed.  This  does  not  tell  the  whole  story.  It  was  excessively 
difficult  to  trace  the  cases  in  this  trade,  which  employs  so  many  non-English 
speaking  Slavs  but  it  so  happened  that  I  was  able  to  make  an  intensive  study 
of  148  men  who  were  at  the  time  out  on  strike  and  I  found  that  one  in  three 
is  probably  the  real  proportion  poisoned.  Among  these  148  men,  54  or  36 
per  cent.,  showed  evidence  of  chronic  plumbism  and  38  others  were  not  beyond 
suspicion.  The  form  of  lead  poisoning  among  enamellers  is  often  severe; 
28  cases  of  palsy  were  found,  and  eight  of  the  cerebral  form  of  plumbism. 
Twelve  were  said  to  have  been  fatal,  but  only  seven  of  these  were  reported 
by  doctors.  In  Germany  this  is  a  leadless  trade,  the  enamel  used  being  lead- 
free  and  applied  wet.  In  England  it  is  leadless  in  some  places,  but  in  other 
factories  a  lead  enamel  is  used  and  in  these  places  the  employers  are  obliged 
to  follow  strict  rules  for  the  protection  of  the  men.  In  Austria  where  a 
similar  method  is  used  for  enamelling  stoves,  there  is,  according  to  Teleky,  a 
great  deal  of  lead  poisoning. 

A  comparison  between  foreign  factories  and  our  own  is  hard  to  make,  but 
in  a  German  pottery  where  glaze  is  made  in  the  same  way  as  enamel  in  our 
country  no  cases  of  lead  poisoning  has  been  reported  among  15  mixers  in  4 


LEAD    POISONING    IN    THE    UNITED    STATES  II3 

years  time,  and  in  an  English  enamelling  plant  where  a  lead  enamel  is  used, 
the  average  of  lead  poisoning  among  26  employees  is  one  in  2  years. 

Lead  Mining. — There  has  been  no  detailed  study  of  lead  poisoning 
among  miners  in  this  country,  but  in  the  course  of  an  investigation  of 
the  smelting  industry,  one  comes  across  cases  in  hospital  records  which 
show  that  the  mining  of  lead  ores  is  not  devoid  of  risk  of  this  sort.  The 
Hospital  of  St.  Vincent  in  Leadville  has  probably  the  oldest  records  of 
lead  poisoning  in  miners  and  smelters  in  the  United  States.  In  1880, 
the  year  after  the  opening  of  the  hospital,  67  miners  and  54  smelters  were 
treated  for  this  disease.  The  next  year  the  miners  numbered  41  and  in 
1882,  54,  while  the  smelters  rose  to  119  and  then  to  424.  For  some  years 
the  cases  among  miners  keep  on  at  about  40  to  50,  as  long  as  the  surface 
ores,  the  sulphate,  carbonate  and  oxides,  continue  to  form  a  large  propor- 
tion of  the  output  of  the  mines,  but  as  the  lower  levels  are  reached  and  the 
ore  contains  largely  lead  sulphide,  galena,  the  cases  of  lead  poisoning  fall 
oflF.  Even  in  1910,  however,  there  were  eight  cases,  but  the  next  year 
only  three  and  in  191 2  all  the  lead  poisoning  came  from  the  smelting 
plants. 

It  is  com.monly  stated  that  lead  sulphide  ore  is  not  dangerous,  because 
the  lead  is  in  a  form  insoluble  in  human  gastric  juice.  This  has  been  held 
by  eminent  authorities  to  be  true,  on  the  basis  of  practical  experience  as  well 
as  animal  experimentation.  Rambousek  stated  at  the  International  Congress 
of  Industrial  Hygiene  in  Milan,  in  1906,  that  there  had  been  no  case  of  lead 
poisoning  among  10,000  Bohemian  miners  while  among  4000  smelters  there 
were  150  cases.  On  the  other  hand,  Biondi  had  seen  such  cases  among  the 
lead  miners  in  Sardinia.  The  animal  experiments  performed  by  Blum  con- 
firm the  theory  of  Rambousek  as  to  the  insolubility  of  lead  sulphide,  while 
those  of  Murgia  and  of  Brezina  and  Eugling,  seem  to  show  that  it  is  absorbed 
by  the  body.^o 

In  the  search  for  cases  of  lead  poisoning  among  the  smelters  of  the  St. 
Louis  region,  I  found  25  cases  which  had  been  treated  in  one  St.  Louis  hospi- 
tal, all  of  the  men  having  come  from  the  lead  belt  of  southeastern  Missouri, 
chiefly  from  Desloge.  The  cases  were  serious  enough  to  require  hospital  care 
and  one  man  had  palsy,  another  a  lead  psychosis.  They  were  foreigners  and 
as  there  is  but  one  small  smelter  in  that  region,  employing  only  Americans, 
they  must  have  come  from  the  mines  and  the  concentrating  mills,  where 
about  a  thousand  foreign  workmen  are  employed  and  where  the  ore  is  exclu- 
sively galena.  To  clear  up  the  question  as  to  possible  poisoning  from  galena 
ore,  Dr.  A.  J.  Carlson,  of  the  Physiological  Department  of  Chicago  University 
undertook  to  test  the  solubihty  of  three  of  these  Missouri  ofes  in  human 
gastric  juice.  He  found  the  solubility  to  be:  1.38  per  cent.,  2.94  per  cent., 
and  3.32  per  cent.,  averaging  about  2.5  per  cent.  There  is,  therefore,  danger 
in  mining  lead  ore  even  when  the  ore  is  pure  sulphide. 


114  OCCUPATIONAL   INTOXICATIONS 

Lead  Smelting  and  Refining. — ^The  United  States  is  one  of  the  largest 
lead-producing  countries  and  in  addition  to  smelting  and  refining  our  own 
ores  we  refine  much  Mexican  bullion.  The  20  plants  which  formed  the 
subject  of  a  Federal  investigation  employ  some  7500  men.  They  are  situ- 
ated in  Perth  Amboy  and  Newark,  N.  J.;  Graselh  and  East  Chicago,  Ind.; 
South  Chicago,  Federal,  Granite  City,  and  Collinsville,  111.;  Herculaneum 
and  Joplin,  Mo.;  Omaha,  Neb.;  Denver,  Leadville,  Pueblo  and  Salida, 
Col.;  Murray,  Midvale  and  Tooele,  Utah,  and  East  Helena,  Mont. 

The  dangers  in  a  smelting  or  refining  plant  are  from  fumes  and  dust  and 
every  man  employed  is  more  or  less  exposed  to  them,  though  in  a  clean,  well 
managed  plant  there  are  parts  which  are  almost  free  from  danger.  In  a 
dusty  neglected  one  there  is  not  a  single  safe  spot.  In  handhng  the  ores, 
dust  is  the  danger,  though  this  varies  according  to  the  dampness  of  the  ore 
and  its  composition,  the  sulphide  ores  being  less  poisonous  than  the  carbonate 
and  oxide  ores.  In  pre-roasting,  in  roasting  and  in  smelting  there  is  danger 
from  dust  while  the  charges  are  being  made  up  and  put  in  the  furnaces,  and 
there  is  great  danger  from  fumes  while  roasting  and  smelting  proceed,  and  of 
both  when  the  furnaces  are  emptied  of  their  dusty  and  fuming  product.  In 
the  later  processes  of  refining  the  danger  is  chiefly  from  fumes. 

The  fact  that  these  processes  result  in  the  evolution  of  lead  fumes  has 
led  to  the  construction  of  elaborate  flues  and  bag  houses  to  catch  and  con- 
dense them.  The  fumes  collect  in  these  in  the  form  of  a  very  fine  powder  and 
the  work  of  cleaning  out  and  transporting  this  powder  to  the  furnaces  is  very 
dangerous,  except  in  one  plant  w^here  it  has  been  made  possible  to  flush  out 
the  flues  with  water,  and  to  empty  the  bag  house  mechanically. 

The  most  dangerous  places  in  an  American  smelter  are:  the  open  or 
Scotch  hearths,  where  the  ore  is  smelted  in  the  open  and  the  men  exposed  to 
fumes  and  to  excessive  heat  and  exertion;  the  emptying  of  the  Huntington- 
Heberlein  roasting  pots,  which  in  this  country  is  always  done  in  a  way  to  cause 
much  dust  and  fume;  the  charging  of  the  blast  furnaces,  which  in  several 
plants  has  been  made  fairh^  safe  but  which  is  usually  bad;  the  tapping  of 
blast  furnaces,  and  the  cleaning  out  of  flues  and  bag  houses.  Other  furnace 
work  may  be  equally  bad  if  poorly  managed  but  it  is  an  easier  task  to  prevent 
fumes  in  refining  processes  than  in  smelting.  It  is  simply  because  of  neglect 
that  American  refineries  are  on  the  whole  worse  than  the  smelters. 

The  provision  of  washing  facilities  for  smelting  employees  is  not  nearly  as 
important  as  the  prevention  of  dust  and  fumes  during  work.  Miiller^^  has 
shown  that  the  amount  of  lead  that  clings  to  a  man's  hands  is  insignificant 
in  comparison  to  what  he  may  be  obliged  to  breathe  in  if  the  work  is  dusty  and 
fumes  escape.  I  have  seen  a  plant  with  an  elaborately  equipped  lavatory, 
bath  house  and  dining  room,  whose  rate  of  plumbism  was  nevertheless  far 
higher  than  that  of  many  plants  with  no  washing  facilities,  because  of  the 
excessive  amount  of  poisonous  fumes  in  the  open-hearth  shed  and  of  dust  in 
the  bag  houses.     If  the  lead  on  the  hands  were  the  great  danger,  there  would 


LEAD    POISONING    IN    THE    UNITED    STATES  II5 

be  more  plumbism  among  refiners  and  desilverers  than  among  furnace  men, 
for  the  former  handle  almost  pure  lead,  but  the  fact  is  that  the  refining 
department  is  the  safest  of  all. 

We  collected  from  physicians'  records  and  from  hospitals,  1667  cases  of 
lead  poisoning  which  occurred  in  i  year,  1912,  in  19  plants  employing 
7400  men.  The  twentieth  had  opened  too  recently  to  be  included.  This 
represents  a  rate  of  a  little  over  22  for  every  100  employed.  The  British 
rate  for  that  year  was  1.8  per  100;  the  reports  of  four  German  smelters 
give  a  rate  of  10  or  11  per  100,  and  in  one  large  Austrian  plant  the  rate 
was  9  per  100. 

Manufacture  of  Storage  Batteries  or  Electric  Accumulators.  ^^ — ^s  the 
use  of  motor  cars  and  of  electric  lighting  increases,  the  demand  for  storage 
batteries  increases.  There  are  a  great  many  small  plants  in  this  country 
engaged  in  the  manufacture  or  repair  of  these  batteries  and  there  are  five 
large  ones  in  which  about  915  men  are  employed  in  work  exposing  them  to 
lead.  These  are  situated  in  Cleveland,  in  Niagara  Falls,  in  Depew  near 
Buffalo,  and  in  Philadelphia. 

The  lead  work  consists  in  casting  lead  grids,  trimming  off  the  irregular 
borders,  mixing  oxides  of  lead  with  other  ingredients,  making  a  paste  of  the 
mixture,  rubbing  and  pressing  this  paste  into  the  grids,  drying  them,  connect- 
ing them  in  pairs  and  groups  by  means  of  pure  lead  melted  with  an  oxy-hydro- 
gen  flame,  carrying  them  to  the  forming  room  where  an  electric  current  is 
passed  through,  and  making  the  final  connections  with  lead  and  the  oxy- 
hydrogen  flame.  Fumes  from  melted  lead  and  dust  from  lead  oxides  and 
from  dried  paste  are  the  dangers  here,  to  which  must  be  added  the  danger 
that  the  poisonous  oxides  smeared  over  the  men's  hands  may  contaminate 
their  food  and  tobacco.  Personal  cleanliness  is  of  great  importance  in  this 
work;  yet  only  one  of  the  five  plants  has  complete  arrangements  for  washing 
and  bathing  and  all  employ  almost  entirely  foreigners  who  have  little  under- 
standing of  how  to  protect  themselves.  We  found  in  the  records  of  doctors 
and  hospitals  164  cases  of  lead  poisoning,  chiefly  acute,  which  had  occurred  in 
1913  in  the  five  plants  employing  915  men,  which  means  a  rate  of  almost  18 
per  cent.  This  figure  is  incomplete,  for  in  the  case  of  two  of  the  plants  it  was 
almost  impossible  to  obtain  any  information.  The  rate  in  this  industry  in 
Great  Britain  was  3  per  cent,  in  191 2.  In  a  great  factory  in  Germany  in  that 
same  year  the  rate  was  0.97  per  cent. 

The  Painters'  Trade.  ^^ — This  is  regarded  in  all  countries  as  the  most 
important  of  the  lead  industries,  for  it  employs  a  large  number  of  men  and, 
as  it  is  a  skilled  and  well-paid  trade,  men  do  not  drop  out  of  it  at  the  first 
attack  of  illness  but  usually  keep  on  till  actually  incapacitated.  It  is  harder 
to  control  conditions  in  the  painting  trade  than  in  any  other  lead  trade  and 
therefore  while  industrial  poisoning  has  been  greatly  diminished  in  other 
occupations,  there  has  been  no  falling  off  in  this  trade  in  Germany  or  Great 
Britain. 


Il6  OCCUPATIONAL   INTOXICATIONS 

In  the  United  States  it  is  impossible  to  make  any  statement  as  to  the 
amount  of  lead  poisoning  for  which  the  painters'  trade  is  responsible.  All 
we  can  do  is  to  gather  scattered  bits  of  information  from  various  sources. 
The  Illinois  Report  has  157  painters  among  578  cases  from  all  trades,  or 
27  per  cent.  Pratt's  report  of  109  cases  includes  no  less  than  42  painters. 
Andrews  quotes  the  record  of  one  New  York  hospital  in  which  59  cases  of 
plumbism  were  treated,  28  of  them  painters,  and  the  proportion  among  his 
60  fatal  cases  was  even  greater,  40,  or  two-thirds.  A  local  district  council  of 
the  national  trade  union  sent  out  a  questionnaire  to  its  members  asking 
among  other  things  as  to  a  history  of  lead  poisoning.  Of  1009  who  answered 
185  gave  a  history  of  lead  poisoning  and  72  a  history  of  kidney  trouble,  77 
of  rheumatism,  27  of  chronic  stomach  trouble. 

In  order  to  gain  some  idea  of  the  extent  of  lead  poisoning  in  the  trade 
E.  R.  Hayhurst^^  made  a  thorough  examination  of  100  able  bodied  painters 
and  found  59  of  them  with  evidence  of  chronic  plumbism.  A  hundred  his- 
tories of  lead  poisoned  painters  showed  a  high  proportion  of  severe  cases, 
39  per  cent,  of  palsy,  9  per  cent,  of  encephalopathy,  8  per  cent,  of  general 
arteriosclerosis.  The  period  of  exposure  before  illness  begins  is  longer  in 
painters  than  in  most  lead  trades.  Only  19  out  of  48  men  had  worked  less 
than  a  year,  21  over  10  years. 

The  most  dangerous  branches  of  this  industry  in  our  country  are:  interior 
house  painting,  ship  painting  and  certain  parts  of  carriage  painting,  because 
these  all  involve  the  dry  sandpapering  of  white  lead  paint,  which  dust-pro- 
ducing work  is  the  most  prohfic  source  of  lead  poisoning  among  painters. 
The  safest  branches  are  the  painting  of  farm  implements,  of  farm  wagons 
and  of  automobiles,  when  this  is  done  on  a  large  scale,  for  hand-work  has 
given  way  to  dipping  by  machinery  and  only  the  final  decorating  needs  brush 
work.  In  smaller  carriage  and  automobile  shops  and  in  the  painting  of 
railway  coaches,  hand-work  persists  and  there  may  be  much  sandpapering, 
especially  on  the  wheels,  and  in  painting  white  milk  carts,  and  the  walls  of 
toilet  rooms  in  Pullman  cars. 

Ship  painting  involves  the  use  of  much  red  lead  which  must  be  sand- 
papered and  must  be  chipped  off  when  a  new  coat  is  to  be  put  on.  As  this 
may  have  to  be  done  in  the  small  unventilated  spaces  between  the  inner  and 
outer  shells  of  the  ship  the  amount  of  dust  inhaled  may  give  rise  to  severe 
poisoning.  E.  R.  Stitt^*^  of  the  U.  S.  Navy  reported  three  cases  of  acute 
plumbism  from  this  source.  The  men  had  been  employed  in  chipping  off 
old  red  lead  paint  from  the  inside  of  a  ship  and  all  suffered  profound  nervous 
symptoms,  maniac  depressive  insanity  in  the  first,  epileptiform  seizures  in  the 
second,  and  what  appeared  like  an  early  stage  of  dementia  pra^cox  in  the 
third.     All  recovered  completely. 

The  prevention  of  lead  poisoning  among  painters  is  fraught  with  much 
difficulty  when  the  work  is  done  outside  a  factory.  House  painting  is  often 
done  in  buildings  where  the  water  has  not  yet  been  turned  on  and  there  is 


LEAD    POISONING   IN    THE    UNITED    STATES  II7 

no  way  for  the  men  to  wash  properly  before  eating  their  lunch.  In  factories 
where  this  could  be  provided  the  arrangements  are  almost  always  quite 
inadequate.  The  dry  sandpapering  of  lead  paint  is  forbidden  by  law  in 
several  countries  and  it  would  be  a  simple  matter  to  do  away  with  it  if  the 
men  could  learn  to  use  a  cheap  mineral  oil  to  moisten  the  paper  and  catch 
the  dust.  The  national  trade  union  has  already  taken  it  up  but  many  coach 
and  carriage  painters  are  outside  the  union  and  they  need  legal  protection. 

Manufacture  of  Rubber  Goods.  ^^ — ^Lead,  chiefly  as  htharge,  but  also  as  the 
basic  sulphate,  is  used  in  compounding  rubber.  The  basic  carbonate  and 
red  lead  are  still  occasionally  found,  but  their  use  has  been  largely  aban- 
doned. The  lead  compounds  are  sifted,  weighed  and  carried  in  open  boxes 
together  with  crude  rubber,  sulphur  and  other  ingredients,  to  mixing  mills, 
where  the  box  is  emptied  and  warmed  cylinders  grind  the  materials  together 
into  a  paste.  As  grinding  proceeds  a  good  deal  of  the  dry  portion  falls  off 
and  is  caught  in  a  mill  pan  and  the  mixer  is  obliged  to  stoop  down  and  with 
a  long  handled  brush  sweep  up  the  powder  and  throw  it  back  into  the  mill. 
This  he  does  repeatedly  for  each  batch  of  rubber  and  he  may  mix  as  many  as 
50  batches  in  a  day. 

The  work  of  sifting,  of  weighing,  and  of  mixing  is  dusty  unless  every  pre- 
caution is  taken  in  handling  the  lead  and  unless  there  is  a  good  system  of 
exhaust  ventilation  in  connection  with  the  sifting  machines  and  the  mills. 
Many  mixing  mills  in  American  factories  have  been  provided  with  hoods  with 
suction  to  carry  off  the  dust,  but  these  hoods  are  usually  poorly  constructed 
and  the  exhaust  seldom  strong  enough  to  be  of  any  value.  Cases  of  lead 
poisoning  have  been  found  to  be  not  uncommon  among  rubber  compounders 
and  mixers  in  our  factories,  especially  those  in  which  the  largest  amount  of 
lead  is  used,  the  footwear  factories,  plants  for  the  manufacture  of  mechanical 
rubber,  and  tire  works.  White  rubber  and  highly  colored  rubber  cannot  be 
compounded  with  lead,  for  the  formation  of  lead  sulphide  blackens  it  and 
spoils  the  color.     Hard  rubber  has  little  if  any  lead. 

There  has  been  no  extensive  study  of  lead  poisoning  in  the  typographical 
trades  in  this  country  nor  in  many  of  the  industries  in  which  metallic  lead  is 
used,  nor  in  the  grinding  and  making  of  paints  and  colors.  Enough  work  has 
been  done,  however,  to  show  that  all  the  lead  industries  of  the  United  States 
need  regulation  and  that  we  can  hardly  hope  to  lower  our  high  morbidity 
rate  till  we  adopt  the  measures  which  have  been  followed  with  signal  success 
in  other  countries. 

REFERENCES 

^  Report  of  Illinois  Commission  on  Occupational  Diseases,  Jan.,  1911. 

2  Bulletin  95,  U.  S.  Bureau  of  Labor. 

^  Reprint  of  Appendix  VI  to  Preliminary  Report  of  the  N.  Y.  State  Factory  Investigating 

Committee,  Mar.,  191 2. 
*  Second  Vol.  of  Report  of  N.  Y.  State  Factory  Investigating  Commission,  1913. 
'  Bulletins  of  U.  S.  Bureau  of  Labor,  Nos.  95,  104,  120,  141,  165,  166. 


Il8  OCCUPATIONAL  INTOXICATIONS 

«  Industrial  Lead  Poisoning.     N.  Y.  Med.  Journ.,  1898,  Vol.  LXVII,  page  322. 
^  Bulletin  of  U.  S.  Bureau  of  Labor,  95. 

8  Bulletin  of  U.  S.  Bureau  of  Labor,  104. 

9  Bulletin  of  U.  S.  Bureau  of  Labor,  104. 

10  Bulletin  of  U.  S.  Labor  Statistics,  141,  Appendix. 

"  MuUer,  Rich. — Bekampfung  der  Bleigefahr  in  Bleihiitten,  Jena,  1908. 

"  Bulletin  of  U.  S.  Bureau  of  Labor  Statistics,  165. 

1'  Bulletin  of  U.  S.  Bureau  of  Labor  Statistics,  120. 

1*  Bulletin  of  U.  S.  Bureau  of  Labor  Statistics,  120. 

15  U.  S.  Nav.  Med.  Bull.,  1912,  VoL  VI,  page  161. 

i«  Bulletin  of  U.  S.  Bureau  of  Labor  Statistics,  166. 


SECTION  VI 
MANGANESE  POISONING 

BY  LOUIS  CASAMAJOR,  M.  D.,  New  York  City,  N.  Y. 

Among  the  many  forms  of  industrial  poisonings  from  mineral  and  metallic 
substances,  there  are  some  which  are  infrequently  seen  on  account  of  the  re- 
stricted use  of  the  substance  or  the  rarity  of  its  occurrence.  Lead,  arsenic 
and  antimony  occur  not  infrequently  in  the  trades,  and  give  poisoning  forms 
which  are  easy  of  recognition.  That  there  are  others,  has  been  known  by 
workers  in  restricted  fields  for  years,  but  on  account  of  the  small  number  of 
workmen  who  were  subject  to  these  forms  of  poisoning,  they  have  been  very 
little  known  by  the  medical  profession  at  large. 

Among  these  rarer  poisonings  we  find  as  one  of  the  most  prominent  that 
due  to  manganese  and  the  manganese  salts.  Manganese  is  a  metal  belonging 
to  the  same  group  as  iron,  and  like  it  forms  both  basic  and  acid  salts.  It  is  to 
some  extent  magnetic,  which  fact  accounts  for  its  name. 

Toxicology. — The  toxicology  of  manganese  is  very  httle  known.  In 
the  first  place  the  comparative  rarity  of  the  metal  and  the  restriction  of  its 
use  in  the  arts,  and,  in  the  second  place,  a  still  greater  restriction  in  the  field 
of  medicine  is  responsible  for  this  fact.  In  therapeutics  we  use  manganese 
mostly  in  external  applications  in  the  form  of  potassium  permanganate, 
and  internally,  to  a  much  less  extent,  as  manganese  dioxide  in  the  anaemias 
and  some  gynecological  conditions.  In  commerce  manganese  is  used  most 
extensively  as  manganese  dioxide  in  the  manufacture  of  oxygen  gas,  while 
other  salts,  especially  permanganates,  have  more  or  less  use  in  certain 
trades. 

Manganese  poisoning  is  also  seen  in  workers  in  industries  dealing  with 
other  metals  or  their  ores  in  which  manganese  exists  as  an  impurity,  and  it 
was  under  such  conditions  that  the  author  met  his  cases. 

Schlockow  in  1879  reported  a  peculiar  disease  among  workers  in  a  zinc  mine 
in  Upper  Silesia,  and  the  symptoms  these  patients  exhibited  were  very  simi- 
lar to  those  later  described  by  various  authors  in  manganese  cases.  It  is 
interesting  to  note  that  in  the  ore  obtained  from  this  mine  there  is  a  consid- 
erable quantity  of  manganese,  and  it  also  contained  lead  and  arsenic  in  small 
amounts.  Possibly  some  of  the  peculiar  symptoms  which  Schlockow  described 
in  his  cases  may  be  due  to  the  presence  of  lead  and  arsenic.  Although  he 
had  no  autopsies  to  confirm  his  opinion,  Schlockow  considered  it  to  be  a  spinal 
cord  disease  which  he  ascribed  to  zinc. 

More  accurate  observations  were  made  by  von  Jaksch  in  1901  in  a  factory 

119 


I20  OCCUPATIONAL   INTOXICATIONS 

where  manganese  dioxide  and  potassium  permanganate  were  used.  Von 
Jaksch  ascribed  the  symptoms  he  saw  to  manganese  and  he  described  a 
chnical  picture  which  corresponds  to  that  later  seen  by  Emden,  Friedel  and 
the  author. 

Symptomatology. — According  to  von  Jaksch  the  principal  symptoms 
are  a  gradual  onset  with  impulsive  laughter,  weeping  and  mental  alteration 
of  many  kinds.  Later,  gait  disturbances  develop,  principally  propulsion 
and  retropulsion.  Romberg  sign  is  marked.  The  gait  may  or  may  not  be 
spastic.  The  reflexes  are  exaggerated.  Besides  this  he  notes  salivation, 
mask-like  face  and  monotonous  voice.  Later  the  mental  symptoms  recede, 
and  the  condition  tends  to  remain  stationary. 

Emden  reported  four  cases  of  poisoning  occurring  in  workers  in  a  mangan- 
ese dioxide  grinding  mill,  where  the  atmosphere  was  heavy  with  manganese 
dioxide  dust.  His  patients  showed  general  muscular  weakness  with  no  atro- 
phy, a  mask-like  face  with  inability  to  whistle.  The  gait  was  unsteady,  and 
there  was  a  tendency  to  fall  forward  on  going  down  an  incline.  Retropulsion 
was  marked.  All  tendon  reflexes  were  active  and  equal.  There  was  a  coarse 
intention  tremor  which  in  some  cases  made  writing  difiicult.  The  voice  was 
unsteady  and  monotonous,  and  one  patient  had  impulsive  laughter.  There 
were  no  sphincter  troubles.  He  reported  finding  manganese  in  the  urine 
of  these  patients,  all  of  whom  developed  the  symptoms  after  having  worked 
a  few  months  in  the  manganese  dust. 

The  author  has  seen  ten  cases  exhibiting  neurological  symptoms  similar  to 
those  above  in  men  who  were  working  in  the  ore  separating  house  of  a  large 
zinc  mine,  in  which  manganese  occurs  as  an  impurity  in  the  ore  to  a  consider- 
able extent.  In  this  mill  the  ore  separation  was  brought  about  both  by  dry 
and  wet  processes.  On  the  floors  devoted  to  the  dry  separation  the  dust  in 
the  air  was  so  thick  that  it  resembled  a  heavy  fog.  The  lower  floor  of  the 
mill  was  devoted  to  the  wet  portion  of  the  separation  process,  and  was  free 
from  dust.  All  of  the  lo  cases  occurred  on  the  floors  where  the  dust  is  thick, 
and,  interestingly,  most  of  them  came  from  the  lowest  floor  of  the  mill  on 
which  the  dry  separation  was  carried  on,  and  hence  where  the  dust  was 
thickest.  None  of  the  patients  came  from  the  dustless  floor  where  the  separa- 
tion under  water  is  carried  on. 

Dust  is  undoubtedly  the  means  by  which  the  poison  enters  the  system. 
Oliver  and  others  have  shown  that  most  of  our  industrial  poisons  are  taken 
in  in  the  form  of  dust,  not  so  much  that  which  is  inhaled  as  that  which  is  swal- 
lowed in  the  saliva,  or  taken  in  with  the  food  handled  by  the  dusty  hands  of 
the  workers.  Von  Jaksch  reports  that  in  the  factory  where  his  cases  occurred 
no  new  poisonings  developed  when  the  dust  was  abolished.  Emden  ascribed 
his  cases  to  the  air  of  the  mill  thickly  laden  with  the  manganese  dioxide 
dust. 

All  the  author's  lo  cases  presented  so  many  symptoms  in  common  that 
there  can  be  little  doubt  that  they  were  due  to  a  common  cause;  and  they 


MANGANESE   POISONING  121 

resemble  so  closely  those  described  by  other  authors  that  one  must  in  all 
fairness  assume  that  manganese  was. the  cause  of  the  difficulty. 

Other  possible  causes  were  considered  in  these  cases.  In  the  first  place, 
zinc  is  the  principal  product  of  this  mine,  and  exists  in  the  ore  in  great  pre- 
ponderence  over  any  other  constituent.  A  careful  study  of  the  literature  does 
not  reveal  any  zinc  poisoning  with  nervous  symptoms  which  can  in  any  way 
resemble  those  mentioned  here.  Popoff  has  described  a  case  of  general 
muscular  atrophy  with  gastro-intestinal  symptoms  occurring  in  a  bronze 
worker,  which  he  ascribes  to  zinc.  Of  course  it  might  as  well,  probably  better, 
have  been  due  to  the  copper,  but  in  any  event  the  cases  here  described  bear 
no  resemblance  to  this  one.  Edsall,  after  an  extended  experience  among 
zinc  workers  believes  that  zinc  never  causes  a  systemic  poisoning. 

In  another  portion  of  the  works  connected  with  the  mine  where  the 
author's  cases  occurred,  where  zinc  occurs  alone,  and  where  the  dust  is  not 
inconsiderable,  no  cases  such  as  described  here  have  ever  occurred. 

The  possibility  of  lead  playing  a  part  in  the  etiology  of  this  condition 
may  be  excluded  when  one  considers  that  the  zinc  recovered  from  this  mine 
is  always  of  the  first  grade,  and  no  measures  are  ever  necessary  to  remove 
the  lead.  First  grade  of  commercial  zinc  according  to  modern  standards 
must  assay  less  than  0.0025  per  cent,  of  lead. 

Another  element  of  possible  etiological  importance  which  was  considered 
here  was  the  use  of  extremely  strong  electromagnets  in  the  ore  separation 
process.  These  magnets  vary  in  strength  between  20,000  and  100,000 
ampere-turns.  It  is  reasonable  to  exclude  this  as  a  causative  factor  for  there 
are  so  many  industries  throughout  the  world  where  workmen  are  constantly 
moving  in  strong  electric  fields  that  were  this  to  be  a  cause,  the  condition 
would  undoubtedly  be  more  commonly  known  that  it  is. 

The  symptoms  and  course  of  the  disease  shown  in  the  author's  cases  is 
as  follows:  After  the  man  has  worked  in  the  dust  for  a  length  of  time  vary- 
ing from  6  months  to  3  years  he  begins  to  notice  that  he  has  difficulty  in 
walking,  the  main  feature  of  which  is  that  he  is  unable  to  walk  down  hill 
slowly.  For  years  the  foremen  and  shift  bosses  in  this  separator  house  have 
noticed  that  from  time  to  time  one  of  the  workmen  will  become  unsteady  on 
his  feet.  This  most  often  manifests  itself  in  that  when  the  workman  would 
go  down  a  slight  incline  with  a  wheelbarrow,  and  then  attempt  to  stop  sud- 
denly he  would  fall  forward  into  the  barrow.  This  condition  was  so  well 
known  that  the  foreman  on  seeing  this  would  say  that  the  man  was  "zinced," 
and  remove  him  to  another  part  of  the  works,  out  of  the  dust. 

On  level  ground  and  up  hill  the  patient  has  no  trouble  at  first,  but  when 
he  starts  to  walk  down  an  incline  he  goes  faster  and  faster  until  at  length  he 
must  run  to  keep  himself  from  falling  forward.  He  is  unable  to  stop  and 
must  keep  on  with  ever-increasing  speed,  until  he  runs  against  some  object 
which  stops  him,  or  falls  down.  Retropulsion  develops  with  this  propulsion, 
and  the  patient  finds  himself  unsteady  on  his  feet  whenever  he  wants  to  move. 


122  OCCUPATIONAL   INTOXICATIONS 

Walking  backward  is  impossible,  for  as  soon  as  the  man  tries  it,  he  falls  back- 
ward or  sits  down.  This  gait  disturbance  is  very  similar  to  that  which  is 
seen  in  paralysis  agitans,  and  this  is  not  the  only  way  in  which  our  cases 
resemble  that  disease.  With  the  onset,  pain  and  stiffness  in  the  legs  were 
noticed  in  four  cases,  insomnia  in  one  and  difficulty  in  writing  in  one.  This 
latter  patient  complained  that  he  could  not  control  his  hand  well  in  writing, 
and  that  the  figures,  he  made  were  smaller  than  those  he  formerly  made,  a 
sign  which  occurs  so  characteristically  in  paralysis  agitans. 

While  the  symptoms  of  this  condition  are  few,  they  are  nevertheless  very 
definite.  The  patient  complains  of  little  except  propulsion,  retropulsion 
and  unsteady  station.  About  half  the  patients  have  difficulty  in  hearing, 
not  due  to  middle-ear  disease.  The  speech  is  slightly  slurring  in  some  cases. 
The  faces  of  all  had  the  flat  mask-like  character  of  paralysis  agitans,  and  there 
was  in  one  a  tendency  to  impulsive  laughter.  Tremor  of  the  tongue  is  com- 
mon as  is  also  a  fine,  static  tremor  of  the  hands.  The  legs  feel  shaky  and 
weak,  and  the  station  is  insecure.  Propulsion  and  retropulsion  in  gait  are 
the  most  characteristic  features.  Asynergia  is  always  present  in  well-devel- 
oped cases.  The  eyes  are  normal  in  every  respect.  Muscular  power  is  well 
preserved.  The  deep  and  superficial  muscle  reflexes  are  always  normal. 
There  is  never  any  rest  tremor  of  the  limbs.  Sensations  are  perfectly  pre- 
served. The  laboratory  offers  little  aid  in  the  diagnosis.  The  blood  never 
shows  the  changes  so  characteristically  seen  in  lead  poisoning.  The  urine 
is  negative  in  those  cases  which  have  been  investigated.  The  Wassermann 
reaction  was  negative  in  the  five  cases  in  which  it  was  used,  and  the  spinal 
fluid  examined  in  three  showed  negative  findings. 

On  the  mental  side  nothing  characteristic  was  found.  One  patient  showed 
at  first  a  definite  intelligence  deterioration  similar  to  that  of  general  paralysis, 
which  later  considerably  improved.  Still  later  he  was  subject  to  attacks  of 
violence  and  temper,  but  these  were  brought  on  generally  from  some  external 
irritative  cause.  Two  patients  complained  of  difficulty  in  memory  and 
attention,  which  was  not  demonstrable  objectively.  Most  of  these  patients 
came  from  a  class  with  little  or  no  education,  which,  combined  with  the 
language  difficulty  made  routine  mental  examination  extremely  difficult. 

Pathology. — Only  one  of  the  author's  cases  has  come  to  autopsy,  and 
here  the  pathological  findings  are  so  peculiar  that  one  is  reluctant  to  speak  of 
them  as  of  nosological  importance,  until  further  similar  observations  may 
confirm  them. 

The  brain  showed  no  gross  changes,  nor  were  any  gross  changes  visible 
in  the  kidneys,  liver  or  the  spleen.  On  microscopic  section  the  kidneys 
showed  a  moderate  degree  of  chronic  interstitial  nephritis.  In  the  liver  there 
was  considerable  biliary  cirrhosis  present,  and  the  Uver  cells  themselves 
contained  a  great  deal  of  pigment,  part  of  which  resembled  lipochrome; 
while  the  majority  of  the  granules  were  iron  containing  and  stained  densely 
with  Prussian  Blue  reaction.     Color  reactions  for  manganese  were  not  ob- 


MANGANESE    POISONING  1 23 

tained  in  the  liver  or  other  organs.  It  is  difficult  to  interpret  the  above 
findings.  Such  a  large  amount  of  iron  in  liver  cells  is  rarely  seen  except  in 
the  severe  anjemias  where  active  blood  destruction  has  occurred.  There 
was  no  severe  anaemia  in  this  case,  and  the  patient  showed  no  other  known 
toxic  element  than  the  manganese  except  alcohol,  which  he  was  said  to  have 
used  to  a  considerable  extent. 

On  section  of  the  brain,  no  large  tract  system  degenerations  were  seen. 
There  was  some  degeneration  of  more  or  less  regular  character  in  the  longi- 
tudinal fibers  in  the  pons  which  run  with  those  of  the  pyramidal  tracts. 
While  these  degenerations  were  regular  enough  to  be  assembled  into  clearly 
defined  tracts,  nevertheless  it  was  not  possible  to  determine  exactly  either 
the  upper  or  lower  level  of  the  tracts  in  question.  The  degenerated  portion 
does  not  appear  to  go  above  the  upper  level  of  the  pons,  nor  does  the  lower 
portion  extend  to  any  appreciable  extent  into  the  medulla.  Here  again  we 
have  a  pathological  change  still  more  difficult  to  interpret  than  that  men- 
tioned above.  In  the  first  place,  the  descending  fibers  in  the  pons  are  not 
altogether  well  known.  The  pyramidal  tract  elements  are  clearly  defined, 
and  those  of  the  fronto-pontine  and  temporo-pontine  tracts  are  fairly  so. 
Undoubtedly  there  are  other  fibers  running  in  these  bundles  besides  those 
mentioned,  but  what  their  origin  and  destination  is  it  is  impossible  to  say. 
In  the  degeneration  seen  by  the  author  in  this  case,  it  is  possible  that  we  are 
dealing  with  descending  degeneration  of  some  fibers,  only  ia  the  portion  from 
the  anterior  border  of  the  pons  downward,  as  though  the  original  focus  of 
the  degeneration  had  occurred  in  the  upper  pon  or  lower  midbrain  and  the 
degeneration  extended  from  there  down.  This  is  pure  supposition,  and  we 
will  need  many  more  autopsies  to  prove  this  contention.  Von  Jaksch  re- 
ported that  he  never  found  any  pathological  lesions  post-mortem,  but  he 
does  not  state  the  detaUs  of  his  investigation. 

Animal  experimentation  has  so  far  offered  no  aid.  Von  Jaksch  was  un- 
able to  produce  any  symptoms  in  dogs  who  were  forced  to  live  in  an  atmos- 
phere of  manganese  dust.  The  author  has  attempted,  in  a  large  series  of 
rabbits,  to  produce  a  poisoning  by  mixing  with  the  food  of  the  animals  the 
dust  from  the  mine,  the  manganese  containing  ore,  the  pure  zinc  ore  and  pure 
manganese  dioxide.  Nothing  was  ever  seen  in  any  of  these  animals  which 
could  in  any  way  correspond  to  the  symptoms  seen  in  the  humans.  Complete 
serial  cross  section  of  the  brain  of  these  rabbits  has  revealed  nothing  abnormal 
in  the  way  of  tract  degeneration,  or  other  pathological  signs.  Likewise  sec- 
tions of  the  Uver  in  none  of  these  animals  showed  iron  or  other  pigmentation, 
as  seen  in  the  one  human  case.  Perhaps  it  is  not  altogether  surprising  that 
symptoms  and  lesions  should  be  lacking  in  these  animals  when  one  considers 
that  the  symptoms  seen  in  the  human  are  almost  exclusively  those  of  gait,  of 
station  and  of  facial  expression.  Such  symptoms  cannot  be  observed  in  four- 
footed  animals,  and  if  there  are  tracts  governing  the  gait  elements  mentioned, 
one  would  not  expect  to  find  them  developed  in  the  least  in  the  lower  animals. 


124  OCCUPATIONAL   INTOXICATIONS 

It  becomes  obvious  then  that  further  investigation  along  the  line  of  animal 
experimentation  must  be  done  with  some  of  the  higher  forms,  in  which  gait 
and  station  disturbances  may  be  observed. 

The  course  of  this  condition  is  very  chronic.  The  prognosis  for  life  is 
excellent,  and  for  recovery  poor.  Generally  the  condition  remains  stationary, 
and  rarely  does  it  progress.  Most  of  the  cases  show  more  or  less  regression  of 
symptoms  following  their  removal  from  the  dust,  but  recovery  has  never  been 
observed. 

Treatment. — The  treatment  is  also  unfavorable,  as  in  other  forms  of 
chronic  metallic  poisoning.  Many  authors  speak  of  baths,  of  electricity  and 
of  massage  and  exercises  as  of  value,  but  while  there  can  be  no  doubt  about 
the  general  value  of  such  therapeutic  procedure,  nevertheless  they  do  not 
seem  to  have  any  particular  therapeutic  excellence  for  manganese.  Elimina- 
tive  measures  in  these  cases  by  means  of  the  kidneys,  the  skin  and  the 
intestines  are  indicated,  as  in  all  cases  of  heavy  metal  poisoning. 

In  prophylaxis  the  greatest  hope  may  be  held  out.  There  can  be  no  doubt 
that  the  intake  of  the  poison  occurs  by  means  of  the  dust,  partly  in  inhala- 
tion, but  more  importantly  in  swallowing.  The  dust  enters  the  gastro-intes- 
tinal  canal  together  with  the  swallowed  saliva,  and  with  the  food  of  the  workers. 
Wherever  it  is  possible  completely  to  remove  the  air  dust  in  mills,  that  is  the 
best  form  of  prophylaxis,  for,  as  von  Jaksch  showed  in  the  factory  where  he 
worked,  no  new  cases  occurred  when  the  dust  was  abolished.  Unfortunately, 
this  is  not  always  possible,  but  modern  methods  of  blasts,  suctions  and 
ventilation  appliances  do  a  great  deal  to  obviate  this  danger,  and  should  be 
installed  wherever  the  danger  exists. 

Personal  cleanliness  on  the  part  of  the  workers  is  a  very  important  factor. 
Properly  equipped  wash  rooms,  where  the  workers  are  obliged  to  wash  and 
change  their  clothes  before  going  to  their  homes  will  do  a  great  deal  toward 
obviating  the  bad  effects.  Possibly  most  important  of  all  is  the  early  recog- 
nition of  the  condition  and  the  rapid  removal  of  the  worker  from  the  dust- 
laden  atmosphere. 

But  few  cases  of  manganese  poisoning  occur  among  many  workers,  so  here, 
as  everywhere  else,  an  element  of  personal  susceptibility  plays  an  important 
part  in  the  etiology.  To  educate  factory  owners  and  managers  where  such 
symptoms  are  apt  to  occur  is  the  most  hopeful  outlook  for  the  prophylaxis, 
for  it  has  been  seen  in  the  mill  where  the  author's  cases  have  occurred,  that 
now  that  the  condition  is  known,  any  man  who  shows  symptoms  even  re- 
sembling those  of  manganese  poisoning  is  immediately  removed  from  the 
dust  and  set  to  work  outside  in  the  open.  As  a  result  of  this,  no  more  serious 
cases  have  occurred  here  in  the  past  3  years,  and  one  or  two  individuals  have 
been  put  to  work  outside  on  account  of  possible  symptoms  which  are  so  slight 
that  a  trained  observer  could  not  with  accuracy  state  that  they  were  due  to 
manganese. 


MANGANESE    POISONING  I  25 

REFERENCES 

Casamajor. — "An  Unusual  Form  of  Mineral  Poisoning  Affecting  the  Nervous  System:  Man- 

ganese(?)."     Journal  of  A.  M.  A.,  Vol.  LX,  1913,  page  646. 
Edsall. — Article  in  "Osier's  Modern  Medicine,"  page  138. 
Emden. — "Zur  Kentniss  der  Metallischen  Vergiften;  Ueber  die  Chronischen  Manganver- 

giftung  der  Braunstein-MuUer."     Deutsch.  Med.  Wchnschr.,  1909,  page  795. 
Popoff. — "Ein  Fall  von  chronischen  Vergiftung   mit  Zinkoxyddampher  und  Experimente 

Ueber  die  Wirkung  einiger  Antifermentative  Mittel."     Berlin,  klin  Wchnschr,  1873, 

page  49- 
Schlockow. — "Ueber  ein  eigenartiger  Riickenmarksleiden  der  Zinkhuttenbeiter."    Deutsch 

Med.  Wchnschr.,  1879,  P^ge  208. 
von  Jaksch. — "Die  Vergiftungen."     Leipsig  u.  Wien,  1910. 
von  Jaksch. — "Manganese  Toxicosis."     Journal  of  A   M.  A.,  Vol.  LXI,  1913,  page  1042. 


SECTION  VII 
MERCURY  POISONING 

BY  LUDWIG  TELEKY  M.  D.,  Vienna. 
Translated  from  the  German  by  LEWIS  W.  FETZER,  M.  D.,  Ph.  D. 

Symptomatology  and  Pathology. — In  every  case  of  poisoning  the  time  at 
which  a  certain  amount  of  poison  is  taken  into  the  organism  is  of  the  greatest 
significance  as  to  the  kind  of  symptoms  which  follow. 

This  statement  seems  obvious  when  we  compare  acute  and  chronic 
alcohol  poisoning  because  in  these  the  differences  are  very  readily  apparent 
even  to  the  layman.  Therefore,  we  imderstand  the  term  acute  poisoning 
to  mean  poisoning  that  occurs  in  a  Hmited  space  of  time,  say  several  hours, 
and  as  a  result  of  taking  one  or  more  doses  of  a  toxic  substance. 

When,  however,  we  attempt  to  define  the  limits  which  bound  the  various 
states  of  poisoning,  namely,  the  acute  versus  the  chronic,  we  encounter 
difficulties.  May  we,  for  example,  designate  as  chronic  that  kind  of  poison- 
ing which  follows  the  third,  or  even  the  sixth,  application  of  blue  ointment? 
Even  though  we  recognize  the  existence  of  transitions  from  the  acute  to  the 
chronic  stages  of  poisoning,  we  are  aware  of  the  fact  that  under  the  designa- 
tion of  chronic  poisoning  we  may  have  the  greatest  of  variations.  Only 
recently  it  was  pointed  out  by  T.  M.  Legge  and  EUman,  that  in  lead  poison- 
ing, which  is  the  most  frequently  occurring  form  of  industrial  poisoning,  the 
symptoms  vary  with  the  time  at  which  the  poison  is  taken.  In  mercurial 
poisoning  the  relation  of  the  time  of  poison  on  intake  to  the  clinical  picture 
evinced  is  even  more  striking  than  in  lead  poisoning.  In  acute  mercurial 
poisoning  the  clinical  picture  is  governed  by  the  manifestations  in  the  intes- 
tinal tract.  As  an  initial  symptom  we  have  profuse  diarrhea  in  addition  to 
the  corrosion  which  may  be  present,  but  this  is  rarely  observed  in  industrial 
cases  of  poisoning  and  is  usually  an  accompaniment  of  poisoning  from 
bichloride  of  mercury  taken  either  by  accident  or  with  suicidal  intent.  The 
stools  of  acute  poisoning  are  feculent  at  the  beginning  but  soon  become 
watery  and  profuse.  In  many  instances  according  to  Kunkle,  the  stools 
become  bloody,  sometimes  contain  pieces  of  mucous  membrane  and  are  of  a 
very  disagreeable  odor.  During  the  act  of  defecation  a  marked  tenesmus  and 
a  severe  pain  in  the  lower  part  of  the  abdomen  are  present.  In  some  cases 
vomiting  occurs  even  when  the  poison  has  not  been  taken  by  way  of  mouth. 

Simultaneous  with  the  occurrences  in  the  intestinal  tract,  renal  symptoms 
become  evident.  These  consist  of  a  marked  reduction  in  the  output  of 
urine,  which  may  go  on  to  a  complete  anuria.  The  urine  in  such  cases  con- 
tains, in  addition  to  renal  epithelium,  white  and  red  blood  corpuscles.     Con- 

126 


MERCURY   POISONING  127 

sciousness  is  not  affected  but  often  the  patients  have  headache  and  a  feeling 
of  fear,  and  near  the  end  somnolence.  With  the  loss  in  strength  death  usually 
occurs  after  several  days. 

When  corrosive  subHmate  is  taken  instant  pain  and  burning  in  the 
mouth  occur  as  a  result  of  the  corrosive  action  of  the  substance,  but  where 
poisoning  is  effected  by  resorption  of  a  solution  of  mercury  through  other 
channels,  as  the  uterus  or  bladder,  the  major  part  of  the  symptoms  in  the 
buccal  cavity  which  play  an  important  role  in  subacute  industrial  poisoning, 
are  absent. 

I  have  never  had  the  opportunity  of  seeing  among  the  numerous  cases 
of  industrial  poisoning  which  have  come  under  my  observation  a  marked 
case  resembling  the  one  described.  Although  I  have  been  informed  of 
the  occurrence  of  slight  diarrheas  and  despite  the  fact  that  I  have  the  idio- 
syncrasy of  becoming  thus  affected  after  washing  in  a  solution  of  bichloride 
of  mercur}',  I  have  never  observed  or  read  of  a  case  of  industrial  mercury 
poisoning  with  pronounced  acute  symptoms.  I  have  described  acute  mer- 
curial poisoning  simply  because  the  probabihty  exists  that  such  cases  may 
happen  as  a  result  of  inhaling  large  amounts  of  mercurial  vapors  in  establish- 
ments where  the  conditions  are  extremely  bad. 

In  subacute  mercurial  poisoning  the  most  prominent  symptom  is  the 
inflammation  of  the  buccal  cavity.  The  patient  complains  of  pain  in  the 
mouth  and  experiences  difficulty  in  chewing  at  a  time  when  other  objective 
symptoms,  save  increased  salivation,  are  lacking.  Loosening  of  the  gums 
soon  follows,  however,  and  they  eventually  swell,  become  red  and  bleed  very 
easily.  From  under  the  reddened  parts  of  the  gums  a  thin  pus  exudes.  The 
entire  mucous  membrane  of  the  buccal  cavity  becomes  involved  in  the  proc- 
ess and  on  the  mucous  membranes  of  the  cheek  and  lips  sharply  defined 
yellow  ulcers  develop,  giving  rise  to  a  disagreeable  odor  from  the  mouth. 

The  stomatitis,  with  which  is  associated  swollen  lymph  and  salivary 
glands  may  reach  a  high  degree  of  severity  and  result,  in  addition  to  the 
loosening  of  the  gums  and  falling  out  of  the  teeth,  in  undermining  the  general 
health  and,  as  the  Uterature  informs  us,  in  a  necrosis  of  the  jaw  bones.  All 
degrees  of  stomatitis  may  result  from  industrial  mercurial  poisoning  and  there 
may  be  gradations  from  the  slightest  to  the  severest  forms. 

Mercurial  stomatitis  is  not  easy  to  differentiate  from  other  varieties  of 
stomatitis  especially  when  other  symptoms  of  mercurialism  are  lacking.  It 
may,  however,  be  differentially  diagnosed  from  chronic  gingivitis,  a  condition 
which  affects  workmen  who  take  no  care  of  their  teeth,  and  one  which  is 
almost  always  found  in  older  men.  Chronic  gingivitis  lacks  all  the  evidences 
of  acute  stimulation.  The  inflammatory  process  confines  itself  to  the  edges 
of  the  gums  and  does  not  extend  to  the  remaining  mucous  membranes. 
Furthermore  the  profuse  salivation  present  in  mercurial  poisoning  is  absent. 
In  the  lighter  forms  of  stomatitis  a  purple  red,  slightly  transparent  line  is 
evident  which,  however,  is  decidedlv  different  from  the  lead  line. 


128  OCCUPATIONAL   INTOXICATIONS 

In  addition  to  the  symptoms  in  the  buccal  cavity  during  mercurial 
poisoning,  there  may  be  minor  manifestations  noticeable  in  the  digestive 
tract,  even  before  the  marked  swelling,  and  pain  in  the  mouth,  and  difficulty 
in  eating  are  evident,  such  as  a  loss  of  appetite  and  slight  diarrhea.  With 
these  manifestations,  and  often  when  all  are  lacking — the  patient  complains 
of  indefinite  pains  in  the  extremities  and  joints.  But  above  all  things  the 
patient  shows  evidences  of  psychic  disturbances  which  are  peculiar  to  mer- 
cury poisoning — Erethismus  mercuralis.  They  consist  of  a  peculiar  form  of 
stimulation  and  timidity  and  are  evident  more  especially  when  the  patient 
is  in  the  presence  of  strangers.  Nothing  will  describe  this  condition  better 
than  the  statements  made  by  the  more  intelligent  class  of  patients,  after 
cure.     A  technologist  narrated  the  following  to  me. 

"As  a  general  thing  I  am  a  very  energetic  person  and  have  taken  part  in 
many  functions,  but  while  affected  with  mercury  poisoning  I  felt  oppressed 
and  uncomfortable,  and  was  as  shy  as  in  my  later  boyhood  days,  in  the  pres- 
ence of  grown  people." 

A  very  intelligent  workman,  who  had  been  engaged  for  many  years  in 
the  experimental  laboratory  of  one  of  the  best  known  Austrian  inventors, 
said: 

"An  invention  had  been  completed,  strangers  came,  and  it  was  decided 
to  demonstrate  to  them  the  manufacture  of  the  respective  commodity.  As 
long  as  I  was  conscious  of  the  fact  that  these  people  were  standing  behind 
I  could  not  proceed  to  move  a  finger." 

A  French  author  relates  an  instance  where  a  stranger  came  into  an  inn 
(or  saloon)  in  which  a  number  of  hat  makers,  affected  with  mercurial  poison- 
ing, were  drinking  wine.  During  the  presence  of  the  stranger  none  of  the 
hat  makers  was  able  to  lift  a  glass  to  his  mouth. 

For  a  time  these  psychic  manifestations  were  regarded  as  hysterical  in 
nature,  but  this  view  has  long  since  been  dispelled. 

The  descriptions  of  manifestations  just  given  are  observable  only  in 
marked  cases.  This  class  of  patients  at  the  outset  complain  only  of  lassitude, 
tiredness  and  nervousness. 

A  further  manifestation  of  the  nervous  system  is  the  mercurial  tremor. 
In  marked  cases  of  irritability  or  erethism  one  can  often  observe  a  slight 
twitching  of  the  facial  muscles,  and  a  slight  trembling  of  the  lingers.  The 
trembling,  provided  the  patient  continues  to  work  with  mercury,  increases  in 
intensity  and  finally  extends  to  all  parts  of  the  body.  In  the  early  stages  of 
the  disease,  and  in  lighter  cases,  only  the  hands  and  lingers  tremble,  but  when 
the  preliminary  stage  has  passed,  the  tremors  become  of  the  characteristic 
type. 

In  addition  to  the  fine  tremors,  which,  however,  are  not  always  present, 
there  may  be  interruptions  by  coarse  contractions  (jerks)  and  fluctuations. 
It  is  these  coarse  shaking  movements  which  characterize  the  mercurial 
tremor.     The  mercurial  tre;mor  also  goes  through  peculiar  variations  inas- 


MERCURY   POISONING  1 29 

much  as  it  loses  in  intensity  after  }2  to  i  minute,  and  then  picks  up  and 
becomes  strong  again.  When  the  disease  is  progressive  there  is  gradual  suc- 
cessive involvement  of  the  arm,  the  head,  the  vocal  musculature,  the  legs 
and  the  trunk,  and  in  consequence  the  entire  body  trembles  and  shakes. 
The  patient  loses  more  and  more  the  control  of  the  muscles,  and  the  tremor 
present  is  of  a  pronounced  intentional  type.  When  at  complete  rest  the 
patient  does  not  tremble;  this  point  is  taken  into  consideration  when  diflFer- 
entiating  the  condition  from  paralysis  agitations  or  the  tremor  of  senility. 
Although  persons  affected  with  mercurial  poisoning  can  perform  heavy  work, 
it  is  utterly  impossible  for  them  to  do  the  kind  which  calls  into  play  the  finer 
muscular  movements.  This  has  been  approximately  expressed  by  an  affected 
workman  "the  lighter  the  body  the  more  difficulty  I  have  in  lifting  it." 

Cases  are  sometimes  noted  where  persons  affected  with  mercurial  poison- 
ing are  still  capable  of  carr^'ing  on  a  line  of  work  to  which  they  have  become 
accustomed  through  years  of  practice,  but  are  unable  to  lift  a  glass  to  the 
hps,  and  already  have  some  difficulty  in  walking.  Some  patients  drop  to 
the  ground  on  their  way  to  work,  and  in  consequence  of  the  fact  that  each 
intentional  movement  will  excite  muscular  contractions,  are  unable  to  rise 
unless  aided  by  others.  Even  this  class  of  patients,  however,  are  able  to 
work  at  their  regular  occupation  in  the  factory. 

Notwithstanding  what  has  been  said  about  these  disturbances  ataxia  is 
never  present,  and  it  is  only  the  shaking  movements  which  make  the  desired 
movements  impossible. 

While  drinking  is  difficult  for  patients  with  light  forms  of  the  disease 
those  affected  with  heavy  forms  are  absolutely  helpless,  and  are  unable  to 
eat  or  clothe  themselves,  without  aid.  In  the  most  severe  cases  the  slightest 
movement  in  bed  will  excite  contractions.  Kussmaul  to  whom  we  are 
indebted  for  an  excellent  book  on  industrial  mercury  poisoning,  desqribes 
cases  of  this  severity.  I  personally  never  had  a  case  of  this  kind  under  ob- 
servation, as  follows: 

"The  entire  body  is  thrown  to  and  fro  and  at  the  same  time  every  group 
of  muscles  and  each  single  muscle  appear  to  be  engaged  in  boundless  activity. 
The  head  moves  incessantly  to  and  fro;  at  times  it  is  jerked  backward  or 
sideward,  the  eyelids  go  up  and  down,  and  the  eyeballs  are  rolled  from  one 
side  to  the  other.  The  alas  of  the  nares  and  the  mouth  are  jerked  up  and 
down,  the  face  is  contorted  into  all  sorts  of  grimaces,  the  jaws  move  one 
upon  the  other,  the  arms  and  legs  tremble  and  jerk  together,  and  every  indi- 
vidual muscle  is  engaged  in  the  process. 

The  convulsions  may  become  so  severe  that  the  combined  strength  of 
several  strong  men  cannot  control  the  jolts,  which  throw  the  patient  to  and 
fro,  and  it  becomes  necessary  to  restrain  the  patient  in  bed  with  strong  straps 
to  prevent  him  from  being  hurled  out  of  bed." 

In  very  light  cases  when  nothing  characteristic  is  present  except  coarse 
or  fine  tremors,  this  tremor  cannot  be  differentiated  from  others,  particularly 
9 


130  OCCUPATIONAL   INTOXICATIONS 

from  the  alcoholic  tremor.  As  the  tremors  become  more  intense  and  char- 
acteristic the  jerking  and  shaking  movements  set  in;  the  tremors  may  be 
sharply  differentiated  from  the  alcoholic  tremor,  the  trembhng  of  Basedows' 
disease  and  lead  poisoning,  and  as  previously  stated  from  the  shaking  move- 
ments of  paralysis  agitation  and  the  intentional  tremor  of  seniHty.  Difficulty 
in  making  a  differential  diagnosis  can  arise  only  when  hysteria  and  multiple 
sclerosis  come  in  question,  but  in  these  there  are  other  nervous  symptoms 
which  will  serve  to  determine  their  nature. 

We  have  now  discussed  the  cardinal  symptoms  of  industrial  mercurial- 
ism,  viz.  stomatitis,  erethism,  and  tremors;  the  method  in  which  these  com- 
bine will  be  discussed  later,  as  well  as  those  which  are  less  characteristic  or 
occur  seldom.  Often  when  the  trembling  is  of  a  high  degree  the  extremities 
become  weak.  This  fact  has  led  the  older  authorities  to  speak  of  paralysis 
as  one  of  the  symptoms  of  mercurialism,  although  it  must  be  said  that 
cases  of  actual  paralysis  have  been  noted. 

Letulle  observed  paralysis  of  the  arms  twice,  and  paresis  of  the  legs  once 
whereas  I  have  noted  radial  paralysis  in  two  patients  affected  with  mercuri- 
alism in  one  of  whom  I  saw  it  develop.  Gilbert  noted  as  a  general  thing 
weakness  of  the  hand  and  digital  extensors  in  lead  and  mercury  workers. 
As  Leyden  has  reported  mercurial  polyneuritis  after  mercury  inunctions  and 
others  (Ketli,  Fawoeski)  as  a  result  of  acute  poisoning  with  corrosive  sub- 
limate, and  as  Heller  has  produced  paralysis  in  animals  by  the  injection  of 
mercuric  chlorid,  mercurial  polyneuritis  undoubtedly  occurs,  but  probably 
very  seldom. 

I  have  already  remarked  about  the  occurrence  of  a  nephritis  in  these  cases. 
On  autopsy  they  show  calcium  incrustations  in  the  kidney.  The  therapeutic 
administration  of  mercury,  even  when  the  mercury  cure  consists  of  giving 
small  doses,  may  lead  to  an  albuminuria  and  cylindruria  (Lang  and  Welander) 
but,  excluding  the  improper  use  of  mercury,  these  conditions  are  transient. 
In  the  literature  no  clear  accounts  of  nephritis  in  industrial  mercurialism  are 
given,  but  I  have  found  albuminuria  in  a  large  number  of  patients  with  indus- 
trial mercurialism  and,  consequently,  I  feel  justified  in  drawing  the  conclusion 
that  the  kidney  is  also  affected  in  the  chronic  form  of  the  disease.  Mercury 
when  administered  cutaneously,  subcutaneously,  and  by  way  of  mouth  for 
therapeutic  purposes,  often  produce  exanthema,  and  according  to  Ehrmann 
the  mercury  exanthema  is  one  of  the  best  known  varieties  of  drug  exanthe- 
mata. 

Although  the  exanthema  may  be  one  of  several  varieties  it  is  very  often 
seen  as  a  scarlatinous  erythema  which  very  frequently  comes  from  the  local 
application  of  mercury,  as  inunction  with  blue  ointment.  The  erythema 
itches  intensely  and  consists  of  punctate,  closely  crowded,  reddened  areas 
which  gradually  conflux  to  a  livid  surface,  that  has  a  higher  temperature  than 
the  adjacent  tissue.  Finally  desquamation  occurs  and  scales  are  cast  off  in 
large  lamellae. 


MERCURY   POISONING 


131 


Collis  appears  to  be  the  only  one  who  has  observed  cases  with  exanthema 
in  industrial  establishments  but  the  case  of  a  midwife  poisoned  as  a  result 
of  washing  in  bichloride  of  mercury  solution,  reported  by  Wengler,  might  be 
included  in  this  category. 

Finally  it  may  be  mentioned  that  mercury  workers  show  a  peculiar  copper 
colored  redness  in  the  trachea  and  the  mucous  membrane  of  the  mouth;  this 
is  regarded  by  Kussmaul  as  a  symptom  of  habitual  mercurialism,  when  weak- 
ness, stimulation  and  tremor  are  also  present.  I  have  often  noted  this  copper 
colored  redness  among  workmen  in  the  mercury  works  at  Idria  when  other 
pathologic  signs  were  absent. 

Patients  with  the  severe  form  of  the  disease  have  a  striking  paleness,  lose 
their  appetite  and  become  emaciated.  In  the  very  worst  cases  the  subjects 
are  said  to  become  cachectic. 

The  three  principal  symptoms  of  subacute  and  chronic  mercurial  poison- 
ing, namely  stomatitis,  erethism  and  tremor,  are  not  present  simultaneously 
in  all  cases,  nor  in  the  same  degree.  We  have  cases  which  present  no  other 
symptom  than  a  stomatitis  and  this  is  especially  true  of  patients  who  take 
up  large  amounts  of  mercury  in  a  relatively  short  time.  This  occurs  in  per- 
sons who  do  fire  gilding.  Stomatitis  may  therefore  be  regarded  as  a  symptom 
of  subacute  poisoning. 

On  the  other  hand,  we  see  patients  in  whom  all  evidence  of  stomatitis  is 
absent,  or  in  whom  it  was  previously  present,  but  who  have  the  mercurial 
tremor  in  an  accentuated  degree.  This  form  is  found  in  hat  makers  and 
others  who  have  imbibed  very  small  amounts  of  mercury  over  a  period  of 
many  years.  I  have  seen  only  one  case  where  a  mercurial  tremor,  and  here 
only  a  of  light  degree,  followed  several  days  of  work  with  mercury.  In 
cases  of  this  character  we  probably  have  to  do  with  persons  who  are  espe- 
cially susceptible  to  the  eflfects  of  mercury.  As  a  rule,  it  is  necessary  to  take  in 
small  amounts  of  mercury  continually  for  months  or  even  years,  or  large 
amounts  repeatedly  at  wide  intervals.  Erethism  is  not  found  in  cases  which 
develop  quickly  nor  is  it  observable,  save  an  intimation,  in  entirely  chronic 
cases.  In  the  latter  the  presence  of  erethism  might  be  presumed  if  the  tremor 
increases  when  the  patient  is  conscious  of  the  fact  that  he  or  she  is  under 
observation. 

Erethism  is  most  distinct  in  those  cases  which  have  the  other  two  symp- 
toms of  mercurialism.  There  are  undoubtedly  cases  in  which  the  period  of 
mercury  intake  was  an  average  one,  but  just  here  we  must  not  lose  sight  of  the 
possibility  that  such  cases  might  result  by  the  imbibition  of  small  amounts  of 
mercury  over  a  long  period  of  time  which  would  produce  only  tremors  and 
then  followed  by  the  intake  of  large  amounts  of  mercury  in  a  short  space 
of  time  which  would  yield  an  acute  symptom  as  stomatitis.  I  will  discuss 
the  quantity  of  mercury  necessary  to  produce  poisoning  in  a  subsequent 
paragraph. 


132  OCCUPATIONAL   INTOXICATIONS 

Receptiveness  for  Mercury. — From  experience  gained  in  the  therapeu- 
tic use  of  mercury  we  have  come  to  know  that  great  differences  exist  among 
individuals  in  regard  to  receptiveness  for  mercury.  Some  have  a  distinct 
idiosyncrasy  to  react  with  it.  Sachur  cites  the  case  of  a  20-year-old  girl 
who  after  an  inunction  with  about  5  grams  of  blue  ointment,  containing  1.5 
grams  of  mercury,  developed  numerous  rhagades  on  the  skin  of  the  forearm 
and  fingers  and  died  with  all  the  manifestations  of  an  acute  mercurial  poi- 
soning, diarrhea,  bloody  stools,  and  nephritis. 

In  the  industries  we  also  find  distinct  differences  in  regard  to  receptivity 
among  the  workmen.  In  these  cases  too  the  workers  do  not  become  affected 
at  the  same  time.  Where  the  conditions  are  not  very  bad  only  a  part  of  the 
workmen  become  affected. 

I  have  observed  an  instance  of  extraordinary  receptivity  in  a  strong 
17-year  old  girl  who  became  affected  with  mercurialism  a  short  time  after 
beginning  work  in  a  hat  factory.  The  first  indication  was  diarrhea,  and  this 
was  followed  some  4  months  later  by  stomatitis,  erethism  and  a  gentle  tremor. 
The  girl,  according  to  her  statement,  was  principally  employed  in  the  dyeing 
department  of  the  factory  where  she  did  not  come  into  contact  with  mercury 
or  mercurial  compounds.  Once  daily,  however,  she  was  compelled  to  spend 
about  20  minutes  in  the  felting  division,  where  several  cases  of  mercurialism 
had  just  occurred,  handling  mouth-wash  water  to  workmen.  The  parents 
and  grandparents  of  the  girl  although  engaged  in  hat  making  and  rabbit  hair 
cutting  (contractors)  were  never,  as  far  as  could  be  determined,  affected  with 
mercurialism. 

I  am  unable  to  say  on  the  basis  of  my  own  observations  whether  age  or 
sex  is  a  factor  in  mercurialism  for  the  reason  that  men  perform  different  kinds 
of  work  than  women,  and  because  the  totally  chronic  form  of  the  disease 
results  from  working  years  in  the  industry.  However,  if  we  use  as  a  basis 
the  knowledge  gathered  in  therapeutics  we  must  regard  women  and  children, 
and  tuberculous,  anaemic,  and  cachectic  individuals  as  most  receptive. 

The  amount  of  mercury  necessary  to  cause  poisoning  is  said  by  Gothlin 
to  be  0.4-1.0  mg.  taken  daily  over  a  period  of  several  months;  this  was  deter- 
mined by  laboratory  tests. 

Tests  made  by  Dr.  R.  Lang,  at  my  suggestion,  showed  the  dustirom  the 
blowing  department  of  a  hat  factory  to  contain  2.338  per  cent,  of  mercury. 
Granted  that  the  air  in  an  establishment  of  this  kind  will  carry  40  mg.  of 
dust  per  cubic  meter,  the  amount  of  mercury  inhaled  by  an  individual  would 
be  5.561  mg.  per  working  day.  Only  0.0576  mg.  of  this,  however,  is  soluble 
in  the  digestive  juices. 

Mercury  on  the  hands  of  workmen  and  workwomen  may  also  gain 
entrance  into  the  body.  In  this  connection  we  have  the  observation  of 
Heim  who  collected  4  mg.  of  mercury  from  the  hands  of  a  scrap  cutteress, 
but  only  0.5286  mg.  of  it  was  soluble. 

As  only  a  small  part  of  the  mercury  on  the  hands  gets  into  the  mouth* 


MERCURY    POISONING  1 33 

it  is  very  evident  that  under  the  most  unfavorable  conditions  a  workwoman 
engaged  in  the  blowing  room  of  a  hat  factory  will  take  in  from  this  source, 
and  by  inhalation,  a  combined  amount  of  mercury  which  is  less  than  the  fig- 
ures reported  by  Gothlin. 

When  we  take  cognizance  of  the  fact  that  Gothlin  observed  cases  of 
poisoning  in  which  mercury  was  taken  over  a  period  of  months,  and  further- 
more that  the  author  has  noted  only  cases  in  the  subjects  employed  in  the 
one  relatively  well-equipped  factory  for  over  10  years,  we  must  conclude 
that  the  smallest  amount  of  mercury  taken  continuously  over  a  long  period 
of  time  will  eventually  produce  manifestations  of  the  disease. 

This  statement,  however,  must  be  amplified  by  mentioning  the  fact  that 
in  all  probability  only  that  portion  of  the  mercury  which  is  resorbed  by  the 
body,  and  not  that  present  in  the  digestive  organs  or  the  mercury  which  has 
gained  entrance  to  the  body  by  other  channels,  is  detrimental.  Notwith- 
standing this,  and  leaving  out  of  consideration  the  entirely  different  condi- 
tions of  resorption  in  the  lung,  we  must  not  lose  sight  of  the  fact  that  resorp- 
tion of  mercury  does  occur  from  the  stomach,  although  the  amount  is  small, 
and  furthermore  that  some  mercury  is  rendered  soluble  during  the  process 
of  intestinal  digestion. 

The  investigation  conducted  by  R.  Lang  in  191 2,  which  I  touched  upon 
above,  yielded  the  following  data  with  rabbit's  hair  which  had  been  treated 
with  a  mercurial  mordant. 

Unblownmixedhair,  digested  with  0.346  per  cent.  HCl  yielded  0.018  per  cent.  sol.  mercury 
then  digested  with  0.346  per  cent.  HCl  +  0.1  per  cent,  pepsin  0.044  per  cent.  sol.  mercury 

then  digested  with  0.2  sol.  of  Na2C03 0.025  per  cent.  sol.  mercury 

then  digested  with  0.2  sol.  of  Na2C03  +  pankreon 0.018  per  cent.  sol.  mercury, 


o.  105  per  cent. 

From  these  data  it  is  evident  that  by  progressive  digestion  the  amount 
of  mercury  rendered  soluble  is  greater  than  by  gastric  juice  digestion  alone. 

We  are  appraised  of  a  similar  behavior  for  lead  by  Legge  and  Goadby 
(Lead  Poisoning  and  Lead  Absorption,  London,  191 2). 

Gothlin  has  determined  that  when  the  amount  of  mercury  inhaled  does 
not  exceed  i  mg.  per  4  cubic  meters  of  air,  practically  all  of  it  is  resorbed. 

From  what  has  been  said  in  the  foregoing  it  is  obvious  that  the  method 
whereby  mercury  enters  the  organism  and  the  kind  of  mercury  compound 
introduced,  is  of  the  greatest  significance  in  mercury  poisoning. 

In  industrial  mercurial  poisoning,  however,  chiefly  the  element  mercury 
(metallic  and  gaseous)  and  mercuric  nitrate  come  into  consideration;  mer- 
curic chloride  and  mercuric  cyanide  are  only  occasionally  etiological  factors. 
The  point  as  to  which  of  the  portions  inhaled,  that  gaining  entrance  to  the 
stomach  with  swallowed  saliva  or  the  part  taken  up  by  the  lungs,  is  the  most 
dangerous  must  be  left  undecided  for  the  present. 

Accordingly  the  greatest  danger  to  those  who  have  to  do  with  mercury 


134 


OCCUPATIONAL   INTOXICATIONS 


lies  in  the  fact  that  mercury  will  volatilize  even  at  ordinary  temperature. 
In  this  connection  Renk  was  able  to  show  that  at  a  temperature  of  io°C, 
I  cubic  meter  of  air  above  an  area  of  3^^  square  meter  of  mercury  would  con- 
tain the  following  amounts  of  mercury: 

5  cm.  above i .  86  mg. 

50  cm.  above i .  26  mg. 

I  meter  above o .  85  mg. 

The  volatility  of  mercury  increases  with  a  rise  in  temperature,  which  is 
shown  by  the  following  table  taken  from  Kunkels'  toxicology,  1901,  page  133: 

Grains  of  Mercury  in  a  Cubic  Meter  of  Air  According  to  Various  Investigators 


Temperature 

Regnault 

Hagen 

Hertz 

o°C. 

0.236 

0.177 

0.00224 

io°C. 

0-305 

0.205 

0.00569 

20°C. 

0.409 

0.231 

0.01430 

30°C. 

0563 

0.276 

0.03083 

40°C. 

0.78s 

0.338 

0.07787 

The  elimination  of  mercury  occurs  briefly  in  the  lowermost  portions  of 
the  intestine  from  where  it  is  discharged  with  the  feces,  and  also  in  the 
urine,  saliva  and  sweat.  The  elimination  from  all  channels  is  slow  and  not 
continuous. 

Oberlander  found  mercury  in  the  urine  190  days  after  giving  the  substance 
in  a  mercury  cure.  The  elimination  in  this  190  days'  period,  however,  was 
not  continuous  for  there  were  often  spaces  of  time,  10  days,  in  which  no 
mercury  would  be  noted  in  the  urine.  In  the  examination  of  organs  of  sub- 
jects succumbing  to  acute  poisoning  the  largest  amounts  of  mercury  were 
found  in  the  kidney,  liver  and  large  intestine. 

Treatment. — In  the  treatment  of  industrial  mercurial  poisoning  it  is 
obvious  that  the  first  thing  necessary  is  to  keep  the  patient  from  all  work 
which  involves  the  slightest  possibility  of  taking  up  mercury.  The  next  thing 
necessary  is  to  bring  about  the  elimination  of  the  mercury — how  far  this  is 
possible  we  are  not  able  to  say — by  stimulating  intestinal  activity,  the  secre- 
tion of  urine  and  secretion  of  sweat  (sweat  baths).  The  administration  of 
sodium  or  potassium  iodide  seems  to  be  indicated  in  these  cases. 

Above  aU  things  these  patients  must  be  strengthened  by  giving  good  food, 
fresh  air,  and  hydrotherapeutic  treatment.  The  stomatitis  is  treated  symp- 
tomatically  with  gargles  and  painting  with  astringent  fluids. 

The  stomatitis  when  appropriately  treated  is  usually  cured  in  the  course 
of  a  few  weeks  and  in  light  cases  in  a  few  days.  The  discharge  of  the  ere- 
thism requires  a  somewhat  longer  period  of  time,  but  it  also  vanishes  com- 
pletely when  the  patient  is  kept  from  mercury  work. 

The  removal  of  the  tremor  in  cases  of  average  degree  of  severity  usually 


MERCURY    POISONING  I35 

requires  several  months  but  in  young  patients  it  can  be  discharged  completely. 
In  individuals  around  and  over  50  years  of  age  the  prognosis  is  not  always 
quite  so  favorable.  I  have  seen  persons  who  had  ceased  working  with  mer- 
cury still  show  a  marked  tremor  5,  6,  15  and  30  years  afterward.  Although  I 
have  repeatedly  seen  marked  improvements  and  even  cures  in  older  patients, 
it  is  always  advisable  to  refrain  from  forecasting  a  favorable  prognosis  in  these 
cases.  In  the  older  literature  many  cases  are  described  in  which  the  mercurial 
tremor  and  the  stomatitis  are  said  to  have  led  to  a  fatal  result.  Mercurialism 
should  most  often  be  regarded  as  an  indirect  cause  of  death  inasmuch  as  it 
lowers  the  vitality  of  the  organism  and  thus  prepares  the  soil  for  a  tubercu- 
lous infection.  With  regard  to  the  effect  which  mercurialism  will  have  upon 
the  progeny  it  is  often  stated  that  mercurial  poisoning  will  produce  abortion 
or  will  tend  to  bring  forth  weak  offspring.  There  are  in  fact  cases  described 
in  the  older  literature  which  support  this  contention.  No  proof  exists,  how- 
ever, to  show  that  mercurialism  in  the  male  has  any  detrimental  influence 
upon  the  progeny. 

REFERENCES 

CoUis. — Report  of  English  Industrial  Inspectors,  1909. 

Kunkel. — Handbuch  der  Toxikologie,  Fischer,  Jena,  1901. 

Lewin. — Die  Nebenwirkungen  der  Arzneimittel,  II,  Auflage,  1893,  Hirschwald,  Berlin. 

Ehrmann. — "Toxische    und    infectiose  Erythema  chemischen  und  mikrobiotischen   Ur- 

sprunges."    Mraceks  Handbuch  der  Hautkrankheiten.     Wien,  1902, 1.  B.,  page  644. 
Lang. — Vorlesungen  iiber  Pathologie  und  Therapie  der  Syphilis.     Wiesbaden,  1896,  II, 

Auflage,  I.  B.,  pages  792-853. 
Leyden. — Ueber  Polyneuritis  mercurial.     Deutsche  med.  Wochenschrift,  1893,  Nr.  31.  ,J^' 
Kussmaul. — Untersuchungen  liber  den  konstitutionellen  Merkurialismus  und  sein  Ver- 

haltnis  zur  konstitutionellen  SyphUis.     Wiirzburg,  1861. 
Gothlin. — Gustav  Fr.  Kvicksilverhaltig  Luft  och  fall  af  kronisk  Kvicksilfverforgiftning  vid 

en  medicinsk  laronstalt.     Hygienisk  Tidskrift,  1909,  page  138,  ref.  Hygienische, 

Rundschau,  191 1,  page  390. 
Teleky. — Die  gewerbliche  Quecksilbervergiftung.     Schriften  des  Instituts  fiir  Gewerbe- 

hygiene,  Seydel,  Berlin,  19 12. 
Giglioli. — Contributo  alia  studio  dell  idrargirismo  professionale  nel  bacino  cinabrifero  del 

M.  Amiata  (Siena).     Ramazzini,  1909). 
LetuUe  M. — Essai  sur  I'hydrargyirisme  professionel  (les  coupeur  de  poll) ;  Revue  d'hygiene 

et  de  police  sanitaire,  1889,  Bd.  XI,  page  40. 
Heim. — Rapport  presente  a  la  commission  d'hygiene  industrielle,  touchant  le  projet  de 

Decret  reglementant  les  conditions  hygieniques  du  travail  dans  les  couperiesde  polls. 

Bulletin  de  I'inspection  de  travail  et  de  I'hygiene  industrielle,  1909,  Nr.  5  et  6  Paris, 

Ministere  de  travail  et  de  prevoyance  sociale. 
Moskauer  Semstwo. — Ueber  die  quecksilberfreie  Fabrikation  der  Filzhiite  in  Russland. 

Moskau,  1911.     Internationale  Hygieneausstellung  Dresden,  1911. 
Levitzky. — Au  sujet  de  la  suppression  de  I'emploi  du  mercure  dans  I'industrie  de  la  couperie 

de  polls.     Revue  d'hygiene  1909,  I,  Heft. 
Martial. — Renee,  Le  nitrate  acide  de  Mercure  dans  I'operation  du  secretage,  son  remplace- 

ment  par  des  corps  non  toxique.     Paris  Masson,  191 1. 
Wengler. — Zeitschrift  fiir  Medizinalbeamte,  1906. 
Oberlander. — Ludwig,  Weiner  Med.  Presse,  i88g 


SECTION  VIII 
NAPHTHA  AND  BENZOL  POISONING 

BY  ALICE  HAMILTON,  M.  D.,  Chicago,  IlL 

A  study  of  the  literature  of  poisoning  from  the  products  of  petroleum  such 
as  naphtha,  benzine,  gasoline,  and  from  the  products  of  coal-tar  distillation, 
such  as  benzol,  reveals  a  great  deal  of  confusion  and  the  student  will  often 
be  left  with  a  question  in  his  mind  as  to  just  which  one  of  the  many  complex 
bodies  belonging  to  these  two  groups  was  involved  in  any  specific  instance  of 
poisoning.  This  is  partly  because  in  the  majority  of  cases  a  mixture  was 
used,  not  a  chemically  pure  substance,  but  it  is  also  true  that  to  distinguish 
between  the  physiological  effects  of  poisoning  by  benzine  and  by  benzol  is 
difficult  if  not  impossible.  The  similarity  of  names  adds  to  the  confusion. 
Benzene  is  a  synonym  for  benzol,  not  for  benzine,  but  it  is  not  always  pos- 
sible to  be  sure,  especially  in  French  and  Italian  reports,  exactly  what  body 
is  meant  when  one  of  these  words  is  used.  Another  confusing  factor  is  the 
similarity  of  uses  of  the  two  groups  of  chemicals.  Though  it  is  clear  that  the 
fumes  in  a  benzol  still  or  in  a  petroleum  refinery  are  of  fairly  well-known 
nature,  it  is  not  possible  to  say  which  will  be  present  in  a  rubber  factory,  a 
dry-cleaning  establishment,  a  varnish  factory,  or  a  room  in  which  motor 
cars  are  tested,  for  both  benzine  and  benzol  are  used  for  all  these  purposes. 
Therefore  it  is  easy  to  see  why  some  observers  have  not  attempted  to  decide 
the  real  nature  of  the  poison  which  was  present,  while  others  have  reported 
their  cases  in  such  a  way  as  to  arouse  doubts  in  the  minds  of  critics. 

V.  Jaksch,^  Roth,^Lewin,^  Rambousek,^  emphasize  the  differences  between 
the  petroleum  distillates  and  the  coal-tar,  holding  that  the  latter  have  a  special 
toxic  action  on  the  central  nervous  system.  Lehmann,^  whose  exhaustive 
article  is  the  most  authoritative  pronouncement  we  have  on  the  question, 
finds  a  difference  in  degree  between  the  toxicity  of  benzol  and  benzine,  but 
not  a  difference  in  kind.  It  seems,  however,  best  to  treat  the  two  classes  of 
substances  separately,  at  the  same  time  realizing  that  in  some  instances  it  is 
not  possible  to  discover  just  what  compound  was  involved. 

Petroleum  and  Its  Distillates.— Petroleum  is  a  dark  brown,  oily  liquid 
derived  from  the  subterranean  distillation  of  vegetable  matter.  It  has  a 
structure  of  enormous  complexity,  differing  in  different  regions.  Pennsyl- 
vania petroleum  contains  a  complete  series  of  hydrocarbons  from  CH4  to 
C16H34,  also  the  solid  hydrocarbons  C35H52,  C27H56  and  CsoHes.  When> 
distilled,  the  lighter  compounds  pass  over  at  3o°C.  to  i7o°C.     These  are  the 

136 


NAPHTHA   AND   BENZOL   POISONING  137 

benzines,  naphthas  and  gasolines  and  contain  60  per  cent,  to  75  per  cent, 
pentane  (C5H12,  b.  pt.  36.3°C.)  according  to  the  boihng  point.  The  com- 
pounds which  distill  at  30°C.  to  7o°C.  are  used  chiefly  for  motor  cars;  those 
at  80°  to  i2o°C.  for  extracting  fats,  as  cleaning  fluids,  and,  in  combination 
with  the  distillates  at  temperatures  up  to  i7o°C.,  in  varnish  and  as  turpentine 
substitute  in  paint.  ^  Next  in  order  of  distillation  comes  kerosene,  illuminat- 
ing oil,  and  then  the  solid  paraffines,  vaseline,  etc.  Different  proportions  of 
these  bodies  are  found  in  petroleum  of  different  regions.  West  Virginia  oil 
is  said  to  have  a  good  deal  more  of  the  heavier  bodies  than  Ohio  oil  and 
Russian  oil  is  heavier  than  American. 

Lehmann^  and  his  colleagues  experimented  with  different  benzines, 
letting  animals  inhale  the  fumes,  and  they  found  the  effect  to  be  irritation  of 
the  respiratory  mucosa,  muscular  twitchings  and  a  slowly  increasing  narcosis. 
Light  benzine  in  large  doses  was  decidedly  less  poisonous  than  the  heavier. 
With  Gundermann,  he  found  that  inhaling  20  mg.  of  light  benzine  had  little 
or  no  effect,  but  when  as  much  as  45  mg.  was  used  they  experienced  a  feeling 
of  impaired  mentality  with  weakening  of  the  will  power.  Much  larger  doses 
were  used  by  FelLx^  in  experiments  carried  out  on  prisoners  in  Bucharest. 
He  administered  benzine  as  one  would  chloroform  for  anaesthesia.  While 
some  individuals  proved  to  be  quite  insusceptible,  even  to  large  doses,  the 
majority  after  inhaling  5  to  15  grams  for  7  to  12  minutes  felt  dizziness, 
nausea,  smarting  of  the  conjunctiva,  and  in  some  cases  burning  in  the  chest 
and  drowsiness.  Larger  doses  caused  sleep  and  anaesthesia,  succeeded  by 
nausea,  vomiting,  headache,  dizziness,  depression  and  drowsiness. 

There  are  several  records  in  the  literature  of  poisoning  after  drinking 
benzine,  but  industrial  benzine  poisoning  always  takes  place  through  the 
inhalation  of  fumes  or  through  skin  absorption,  although  so  far  as  is  known 
the  latter  gives  rise  to  local  symptoms  only. 

The  effects  of  acute  poisoning  from  the  inhaling  of  moderate  amounts  of 
fume  resemble  mild  alcoholic  intoxication,  and  in  dry-cleaning  establishments 
or  rubber  works,  where  the  employees  are  very  familiar  with  the  condition, 
they  speak  of  it  as  "naphtha  jag."  Dufour^  speaks  of  the  excited  gayety  of 
girls  employed  in  poorly  ventilated  dry-cleaning  establishments,  a  gayety 
soon  yielding  to  depression,  headache,  clouded  mentality.  In  the  spring  of 
1913  I  had  the  opportunity,  through  the  courtesy  of  Dr.  J.  H.  Landis,  Health 
Officer  of  Cincinnati,  to  interview  nine  interior  house  painters  who  had 
recently  experienced  the  effects  of  using  a  quick-drying  paint,  containing 
large  quantities  of  benzine,  in  small  and  practically  unventilated  rooms. 
Dizziness,  headache,  spots  before  the  eyes,  dryness  and  choking  in  the  throat, 
burning  of  the  eyelids,  were  complained  of  by  all,  while  some  complained  also 
of  nausea,  vomiting,  pains  in  various  parts  of  the  abdomen,  and  painful 
urination.  Several  said  that  at  the  end  of  the  day  they  could  no  longer  do 
fine  work  and  two  had  attacks  of  momentary  blindness.  One  suffered  from 
ulcers  of  the  lips  and  gums.     In  several  instances  the  worst  discomfort  came 


138  OCCUPATIONAL   INTOXICATIONS 

on  leaving  work,  the  dizziness  and  staggering  coming  on  in  the  open  air. 
Loss  of  appetite  and  a  feeling  in  the  morning  of  having  been  drunk  the  night 
before  were  usual  features  of  this  mild  benzine  poisoning. 

More  serious  symptoms  follow  exposure  to  heavier  fumes.  Lewin^  says 
that  in  the  oil  regions  of  Pennsylvania  and  in  the  refineries  at  Point  Breeze 
he  was  told  of  men  who  when  they  went  down  into  the  tanks  became  so 
excited  and  irrational  that  they  could  with  difficulty  be  persuaded  to  come  out. 
In  still  more  serious  cases,  which  are  rare  in  proportion  to  the  numbers  em- 
ployed, there  is  a  rapidly  increasing  weakness,  quick  and  weak  pulse,  labored 
respiration,  delirium  and  coma.  A  physician  in  a  town  where  there  is  a  large 
rubber  factory  told  me  of  such  a  case  in  his  practice.  The  patient,  a  strong 
man,  had  been  dipping  wooden  forms  in  a  tank  filled  with  a  solution  of  rubber 
in  benzine,  to  make  seamless  surgeons'  gloves.  He  felt  dizzy  and  ill  and  left 
work,  but  on  his  way  home  he  staggered  and  would  have  fallen,  had  not  two 
men  helped  him.  Later,  when  in  bed,  he  lapsed  into  unconsciousness  and 
when  the  physician  saw  him  he  was  comatose,  very  pale  and  almost  pulse- 
less.    He  recovered  completely. 

Wichern^^  describes  an  accident  in  a  benzine  tank  where  some  remnants  of 
benzine  were  floating  on  the  surface  of  the  water  poured  in  to  clean  it.  A 
man  who  climbed  in  was  overcome  by  fumes  and  fell  with  his  face  in  the 
benzine.  He  was  quickly  rescued  but  was  unconscious,  his  muscles  strongly 
contracted.  He  had  severe  chills  and  vomiting  and  though  he  recovered 
he  had  some  irritation  of  the  throat  for  2  weeks. 

Cleaning  out  vats  and  tank  cars  is  one  of  the  most  common  causes  of  acute 
benzine  poisoning.*  The  latest  report  of  the  German  Factory  Inspectors^'' 
tells  of  a  workman  who  entered  the  benzine  cylinder  of  a  washing  machine  in 
a  dry-cleaning  establishment  while  there  was  still  some  benzine  left  in  it,  and 
was  found  lying  unconscious  overcome  by  the  fumes,  although  the  machine 
stood  by  an  open  door.  Fumes  from  the  benzine  used  in  quick  drying  paints 
were  responsible  for  two  cases  of  poisoning  noted  in  the  last  report  of  the 
British  Factory  Insepctors.^^ 

Another  industry  which  is  an  increasingly  important  source  of  benzine 
poisoning  is  the  automobile.  Gowers^*  has  reported  a  very  interesting  case 
of  pseudomyasthenia,  involving  chiefly  the  muscles  of  the  throat  and  tongue, 
in  a  tester  of  motor  cars  who  was  continually  exposed  to  fumes  of  gasoline  in 
a  state  of  incomplete  combustion.  In  our  own  country  Potts^^  has  described 
a  case  of  "encephalitis"  due  to  gasoline  poisoning  in  a  man  who  worked  for 
4  months  filhng  automobile  tanks.  After  about  2  months  of  headache, 
nausea,  and  visual  disturbances,  he  fell  unconscious  while  at  work  and  when 
aroused  complained  of  intense  headache.  There  was  weakness  of  the  right 
third  nerve  and  of  the  left  side  with  partial  incoordination  of  the  left  arm 
and  the  gait  was  cerebellar  in  type.  The  weakness  of  eye  and  arm  were 
permanent. 

A  very  extensive  instance  of  gasoline  poisoning  occurred  in  the  digging  of 


NAPHTHA   AND   BENZOL   POISONING  1 39 

a  tunnel  in  Montreal  and  involved  no  less  than  42  cases.  Fumes  from  the 
gasoline  engine  were  responsible. 

Fatal  cases  are  rare.  Lehmann^  has  collected  several  from  the  literature 
and  added  one,  a  man  who  spilled  40  liters  of  benzine  in  a  low  cellar,  tried  to 
scoop  it  up,  came  out  complaining  of  feeling  faint  and  tired  and  a  half  hour 
later  was  found  lying  dead  outside  the  door.  Zimmermann's^^  fatal  case 
died  while  trying  to  remove  with  benzine  the  crusts  which  had  formed  on  the 
inside  of  a  tank.  Lewin^  heard  of  fatal  cases  of  poisoning  in  the  American  oil 
fields  and  refineries  among  the  workmen  who  have  to  enter  the  tanks.  One 
of  the  English  cases  of  poisoning  from  the  use  of  benzine  in  paint  ended 
fatally.  These  paints  are  especially  dangerous  when  the  surface  to  be 
painted  is  warm. 

A  striking  case  of  fatal  poisoning  by  petroleum  products  is  given  by 
Korschenewski,^''  who  has  had  long  experience  in  the  Russian  oil  regions.  A 
healthy  young  man  had  worked  all  day  at  the  pumps  which  control  the  flow 
of  naphtha  from  a  well.  At  evening  he  felt  weak  and  ill.  The  next  morning 
he  expectorated  quantities  of  tarry  blood  which  did  not  redden  on  exposure 
to  the  air.  By  noon  he  was  jaundiced,  there  were  purpuric  spots  in  the  skin, 
vomiting  of  blood,  delirium,  convulsions,  and  death  on  the  following  day.  As 
we  shall  see  later  this  resembles  closely  some  of  the  cases  of  fatal  poisoning 
from  benzol. 

Chronic  benzine  poisoning  is  said  by  many  to  be  rare,  the  workers  in 
rubber  factories,  dye-houses,  etc.,  having  no  more  ill  health  than  falls  to  the 
lot  of  all  factory  people.  Lehmann^  and  Goldschmidt^^  say  that  German 
benzine  workers  show  little  if  any  effect  from  the  fumes  and  Lewin*  found  the 
ordinary  work  in  American  oil  wells  and  refineries  to  be  attended  with  no 
noticeable  effect  on  health.  On  the  other  hand  Russian  writers,  who  have  had 
experience  in  establishments  where  conditions  are  bad,  find  much  ill  health 
traceable  to  the  constant  inhaling  of  benzine  fumes.  Berthenson^^  reviews 
the  literature  on  this  subject  and  shows  that  in  workers  who  are  employed  for 
long  periods  there  develops  bronchial  catarrh,  dyspepsia,  malnutrition, 
anaemia,  nervous  derangements  (Korschenewsky,  Petkewitch).  In  the  Baku 
oil  region  among  8465  employees  there  were,  in  1895,  1475  cases  of  respiratory 
disease,  chiefly  bronchial  catarrh,  and  12 16  cases  of  skin  disease. 

Dorendorff's-"  cases  are  usually  quoted  as  striking  instances  of  chronic 
benzine  poisoning.  The  men  were  rubber  workers  and  the  most  prominent 
symptoms  complained  of-  were  pains  of  a  tearing  character  in  muscles  and 
joints,  tenderness  on  pressure,  weakness  and  coldness  of  the  right  hand, 
psychic  depression,  loss  of  memory,  difficult  speech.  There  was  increased 
excitabiUty  of  the  skin  to  mechanical  irritants  and  heightened  tendon 
reflexes. 

In  addition  to  poisoning  from  fumes  there  is  a  toxic  action  exerted  on  the 
skin  by  the  petroleum  products,  especially  the  heavier.  Paraffin  workers 
develop  multiple  papillomata,  or  pemphigus-like  or  eczematous  eruptions. 


I40  OCCUPATIONAL   INTOXICATIONS 

Benzine  also  causes  skin  lesions.  Last  year  many  cases  of  skin  diseases 
were  reported  from  the  printing  trades  of  Berlin,'^  and  were  traced  to  the 
introduction  of  a  new,  benzine-containing  fluid  for  cleaning  ink  from  type. 
The  disease  was  described  as  a  localized  eczema,  with  redness,  tenseness, 
blisters  and  later  scaling. 

More  often  the  lesions  caused  by  contact  of  the  skin  with  petroleum  are 
described  as  typical  acne  lesions.  Lewin^  found  this  in  the  American  oil 
country.  The  irritating  effect  of  the  oil  causes  inflammation  of  the  sebaceous 
ducts,  retention  of  secretion,  suppuration,  multiple  skin  abscesses,  etc.  In 
the  great  factories  for  agricultural  implements  in  this  country  the  men  and 
girls  employed  in  the  preparing  and  spinning  rooms  in  the  twine  mills  often 
suffer  from  very  distressing  acne.  This  twine  is  treated  with  a  mixture  of 
fuel  oil  95  per  cent,  and  wool  oil  5  per  cent,  to  soften  it  and  keep  it  from  being 
devoured  by  field  insects  when  it  is  in  use.  The  workers  feel  the  effects  of 
this  oil  most  in  summer  when  they  work  with  their  sleeves  rolled  up  because 
of  the  heat. 

Benzol. — Pure  benzol  is  CeHe  and  boils  at  8o.4°C.,  but  the  commercial 
variety  contains  substitution  products  as  well,  chiefly  toluol  and  xylol,  dis- 
tilling at  80°  to  85°C.  It  is  a  solvent  for  rubber,  fats,  gums,  celluloid,  and 
therefore  much  used  in  industry,  but  not  as  much  in  this  country  as  benzine. 
Commercial  benzol  contains  also  a  trace  of  carbon  bisulphide,  and  there  is 
a  variety  used  in  Germany  in  the  rubber  trade  and  for  varnish  which  has 
16  per  cent,  or  even  60  per  cent,  of  this  compound. 

Lehmann^  and  his  colleagues  and  Chassevent  and  Garnier^^  have  come 
to  the  same  conclusions  as  the  result  of  animal  experiments,  namely,  that 
the  symptoms  caused  by  crude,  by  commercial  and  by  pure  benzol  are  the 
same  in  kind  but  that  the  action  of  the  first  two  is  more  rapid  and  intense 
because  of  the  presence  of  toluol  and  xylol,  both  of  which  are  more  toxic 
than  benzol.  Rambousek,^  however,  finds  pure  benzol  more  poisonous 
than  the  two  others  and  so  do  Agasse-Lafont  and  Heim.^^ 

Symptoms. — The  symptoms  caused  by  the  inhalation  of  these  fumes 
point  to  a  poison  with  a  selective  action  on  the  central  nervous  system,  and 
they  are  as  follows  in  the  order  of  their  appearance:  muscular  tremors,  saliva- 
tion, violent  twitchings,  exhaustion,  paralysis,  narcosis,  respirations  first  quick 
then  slow,  rapid  pulse,  low  temperature.  Usually  the  animal  recovers  but  cats 
may  show  a  striking  idiosyncrasy  and  die  after  a  short  exposure,  from  respira- 
tory failure.  Lehmann^  found  no  characteristic  changes  in  organs  or  blood 
but  Chassevent  and  Garnier^^  found  congestion  of  the  abdominal  organs  and 
peritoneum,  and  ecchymoses  and  ulcers  along  the  upper  border  of  the  stomach 
in  the  mucous  coat,  Santesson,^^  experimenting  with  crude  and  with  pure 
benzol,  was  able  to  produce  hemorrhages  into  the  mucous  membrane  of  the 
stomach  and  the  intestines  and  into  the  lungs.  He  concludes  that  benzol 
dissolves  the  body  fat  and  that  emboli  of  fat  lodge  in  the  smaller  vessels 
causing  first  stasis  and  then  rupture  of  the  vessel  wall.     Selling^^  found  blood 


I 


NAPHTHA   AND   BENZOL   POISONING  I4I 

changes  in  rabbits  as  a  result  of  poisoning  with  pure  and  with  commercial 
benzol,  the  most  striking  feature  being  a  leucopenia  which  progressed  till 
the  white  corpuscles  numbered  20  in  a  cubic  millimeter  of  blood.  He  thinks 
benzol  a  specific  poison  for  the  leucocytes.*  In  human  beings,  benzol  is 
decidedly  more  toxic  than  benzine.  Lehmann  and  Gundermann^  produced 
symptoms  in  themselves  with  10  grams  of  benzol  which  required  45  grams  of 
benzine  to  produce.  They  consider  it  a  poison  of  only  moderate  severity, 
while  Rambousek'*  finds  the  vapors  of  benzol  mixed  with  air  very  poisonous 
and  publishes  a  large  number  of  serious  and  of  fatal  cases  collected  from  the 
literature  and  from  personal  information. 

The  majority  of  serious  cases  of  benzol  poisoning  have  occurred  in  work 
which  exposed  the  man  to  very  heavy  fumes,  usually  in  the  cleaning  out  of 
some  receptacle  in  which  benzol  had  been  kept  and  which  in  some  cases 
still  had  remnants  left  when  the  cleaning  began.  Other  men  were  at  work 
with  benzol  stills  where  from  some  accident  or  neglect  fumes  were  allowed 
to  escape.  Slower  forms  have  been  observed  in  rubber  works,  dyeing  and 
cleaning  establishments,  in  a  cannery  where  a  solution  of  rubber  was  used 
instead  of  solder.  The  fatal  case  reported  by  the  factory  inspectors  in 
Great  Britain  in  1912^^  was  employed  in  a  benzol  still,  the  two  German 
cases  in  this  same  year^^  were  employed,  one  in  a  still,  the  other  in  us- 
ing coal-tar  paint,  and  the  two  Austrian  cases, ^^  also  fatal,  were  in  rubber 
works. 

Coal-tar  paint  is  coming  into  use  increasingly  in  recent  years  as  an  anti- 
rust  paint  for  iron  and  steel.  When  used  in  the  open  air  as  in  bridge  paint- 
ing, not  much  discomfort  is  experienced  by  the  painters  but  when  it  is  applied 
hot  and  fuming  in  an  enclosed  space  there  may  be  actual  poisoning  from  it. 
Last  year  when  inspecting  the  paint  department  of  one  of  the  great  ship 
yards  I  found  a  paint  in  use  consisting  of  Trinidad  asphalt  in  coal  tar. 
This  was  applied  hot  to  the  tanks  and  the  water  bottoms,  a  term  used  for 
the  space  between  the  inner  and  outer  shells  of  the  hull.  Dense  white  fumes 
escaped  from  the  hot  mixture  which  were  irritating  and  nauseous  to  me  at  a 
distance  of  15  ft.  and  in  the  open  air,  but  the  men  seem  to  establish  a  certain 
tolerance  to  it.  Certain  ones,  however,  are  more  susceptible  and  I  was 
told  of  instances  of  semi-intoxication,  coming  on  either  during  work  or 
on  reaching  the  open  air,  and  one  case  of  wild  delirium,  which  subsided 
into  confusion  and  bewilderment  when  the  man  was  brought  to  the  fresh 


air 


10 


The  descriptions  of  the  serious  cases  of  benzol  poisoning,  when  given  in 
detail,  vary  a  good  deal,  yet  all  present  the  picture  of  intoxication  by  a 
substance  with  a  specific  action  on  the  central  nervous  system.  In  addition, 
there  are  a  number  of  instances  of  lesions  of  the  blood-vessels  leading  to 
multiple  hemorrhages.     The  Austrian  factory  inspectors  report  in    191 1" 

*  Other  blood  changes  noted  are  (Simonin^^)  a  transient  eosinophilia  of  25  per  cent., 
and  (Dorendorff^")  a  brown  pigment  in  the  plasma  and  leucocytes. 


142  OCCUPATIONAL   INTOXICATIONS 

two  fatal  cases  of  an  unusual  illness  in  rubber  workers,  characterized  by 
purpuric  spots  on  the  body  and  found  to  be  caused  by  benzol  fumes. 

Lenoir  and  Claude^^  tell  of  a  fatal  case  of  purpura  in  a  workman  employed 
for  several  years  in  a  dye  house  and  exposed  daily  to  fumes  of  benzene. 
There  were  subcutaneous  hemorrhages,  bleeding  from  nose  and  from  gums, 
increasing  cachexia  and  sudden  death.  At  autopsy,  bloody  effusion  into 
the  pleural  cavity,  hemorrhages  into  the  mucosa  of  stomach  and  intestines 
and  under  the  endocardium,  myocardial  infarcts. 

Santesson^^  has  described  the  most  famous  cases  in  the  literature  of 
benzol  poisoning.  Nine  young  women  were  employed  for  periods  of  a 
few  weeks  or  months  in  a  velocipede  tire  factory  in  Upsala.  For  a  while 
before  the  appearance  of  the  most  serious  symptoms  they  had  been  working 
overtime,  12  hours  or  more  a  day.  The  symptoms  complained  of  were 
usually  those  already  described  as  characteristic  of  acute  benzol  poisoning, 
but  the  more  serious  cases  had  in  addition  purpuric  spots  on  the  skin  and  a 
tendency  to  hemorrhage,  sometimes  excessive,  from  nose,  mouth  or  gums. 
In  one  there  was  a  menstrual  hemorrhage.  Four  girls  died,  after  illnesses 
lasting  a  month  or  two.  Profound  anaemia  developed,  in  the  third  case 
reaching  600,000  reds,  and  the  fourth  case  had  a  striking  leucopenia,  hardly 
any  whites  being  discoverable  in  a  cubic  millimeter  of  blood.  Santesson 
found  that  the  solution  used  in  the  factory  was  a  crude  coal-tar  benzol 
distiUing  at  80°  to  9o°C. 

Lehmann^  thinks  that  the  severity  of  these  cases,  so  much  greater  than 
any  reported  in  the  literature  and  with  the  unusual  feature  of  purpuric 
lesions,  is  to  be  explained  on  the  ground  of  the  youth  and  sex  of  the  victims 
and  the  overexertion  to  which  they  had  been  exposed.  Three  almost 
precisely  similar  American  cases  reported  by  Selling-^  seem  to  have  escaped 
Lehmann's  attention.  These  also  were  young  girls,  younger  than  the  Swed- 
ish cases  for  they  were  only  14  years  old,  and  it  is  this  immaturity  which 
probably  explains  the  more  rapid  course  of  the  disease  in  Selling's  cases. 
The  girls  were  employed  in  a  cannery  near  Baltimore  where  recently  a  solu- 
tion of  rubber  and  rosin  in  commercial  benzol  had  been  substituted  for 
solder  in  the  sealing  of  cans.  The  work  was  done  in  a  well-ventilated  room 
and  there  is  no  note  of  excessive  hours,  but  it  was  during  the  summer  months 
when  the  heat  in  Maryland  is  intense.  Three  girls  were  brought  to  the  Johns 
Hopkins  Hospital  suffering  from  anaemia,  purpuric  spots,  dizziness,  hemor- 
rhages from  throat,  nose  and  gums.  As  in  Santesson's  cases,  the  symptoms 
increased  after  the  exciting  cause  had  ceased  and  two  of  the  three  girls  died 
in  a  few  days  with  symptoms  of  profound  toxaemia.  There  was  a  count  of 
only  1,090,000  reds,  falling  before  death  to  640,000,  and  the  hemoglobin 
fell  to  8  per  cent.,  but  leucopenia  was  the  most  striking  feature  of  the  blood 
picture.  The  whites  numbered  only  480  per  cu.  mm.  and  the  loss  affected 
chiefly   the  polymorphonuclears,   which  formed    16  per    cent.,   the   small 


NAPHTHA   AND   BENZOL   POISONING  1 43 

mononuclears  forming  71  per  cent,  and  the  large,  10  per  cent.*  Selling 
calls  the  condition  one  of  aplastic  anaemia,  for  in  spite  of  the  great  loss  no 
regenerating  forms  of  blood  corpuscles  were  found.  He  found  the  substance 
to  be  crude  benzol  chiefly,  and  with  it  as  also  with  pure  benzol  he  was 
able  to  bring  about  in  rabbits  a  marked  leucopenia,  reaching  20  per  cu.  mm. 
at  which  point  death  occurred. 

It  is  worth  noting  that  in  Selling's  cases  and  in  two  of  Santesson's  there 
was  fever,  while  in  experimental  benzol  poisoning  a  fall  of  temperature 
seems  to  be  invariable. 

Preventive  Measures. — The  prevention  of  poisoning  from  fumes  of 
benzol  or  benzine  lies  in  good  ventilation  so  that  the  fumes  may  be  diluted 
down  to  the  point  of  harmlessness.  Even  allowing  for  an  individual  sus- 
ceptibility such  as  we  have  reason  to  think  does  exist  in  some  people,  the 
really  serious  cases  of  poisoning  have  all  been  caused  by  exposure  to  very 
heavy  fumes,  and  the  reports  of  chronic  poisoning  come  from  those  countries 
chiefly  where  industrial  hygiene  is  comparatively  neglected.  High  ceilings, 
abundant  ventilation,  scrupulous  cleanliness  are  enough  in  cases  where  fumes 
are  not  heavy;  artificial  ventilation  with  air  exhaust  must  be  installed  when 
the  danger  is  greater,  preferably,  according  to  the  British  inspectors,  with  a 
down-draft  as  these  are  heavy  fumes.  If  a  vat  or  tank  must  be  cleaned  out, 
the  men  must  be  furnished  with  divers'  helmets.  For  the  distressing  skin 
diseases  nothing  but  very  strict  bodily  cleanliness  wiU  help  and  in  suscepti- 
ble cases  there  is  no  hope  of  cure  as  long  as  the  work  is  kept  up. 

REFERENCES 

^  Von  Jaksch. — Die  Vergiftungen  Vienna,  1914. 

2  Roth. — Kompendium  d.  Gewerbekrankheiten,  Berlin,  1909. 

^Lewin. — Miinch.  med.  Wchschft.,  1907,  Vol.  LIV,  page  2377. 

*  Rambousek.— Concordia,  1910,  Vol.  XVII,  page  448. 

^  Lehmann.-^Weissenberg,   v.   Wojciechowski,  Luig,   and  Gundermann.     Arch.  f.  Hyg., 
191 1,  Vol.  LXXrV,  page  i. 

^  Bartley. — Medical  and  Pharmaceutical  Chemistry,  Philadelphia,  1899. 

'  Felix. — Quoted  by  Lehmann. 

^Lewin. — Virchow's  Arch.,  1888,  Vol.  CXII,  page  35. 

'  Dufour. — Soc.  med.  d.  Hop.  d.,  Paris,  Oct.  18,  1901. 

"  Hygiene  of  the  Painters'  Trade.     Bulletin  120  of  the  U.  S.  Bureau  of  Labor  Statistics. 
"  Wichern. — Miinch.  med.  Wchschft.,  1909,  Vol.  LVI,  page  2. 
12  Jahresbericht  d.  Gewerbeaufsichtsbeamten  u.  Bergbehorden  f.  d.  Jahr.,  1912,  Vol.  Ill, 

pages  15  and  17. 
^'  Annual  Rep.  Chief  Inspector  Fact,  and  Workshops  for  191 2,  page  102. 
"  Gowers. — Ramazzini,  1908,  Vol.  II,  page  225. 
"  Potts. — Jour.  Nerv.  and  Ment.  Dis.,  1914,  Vol.  XLI,  page  527. 
^' Zimmermann. — Ztschft.  f.  Gewerbehyg.,  1907,  page  157. 
^^  Korschenewsky. — Quoted  by  Lehmann  and  by  Berthenson. 
"  Goldschmidt.— Weyl's  Hb.  d.  Hygiene,  Vol.  VIII,  pages  859  and  884. 

*  The  resemblance  of  these  symptoms  to  those  of  scurvy  is  striking,  especially  as 
V.  Jaksch  found  leucopenia  in  scurvy. 


144  OCCUPATIONAL   INTOXICATIONS 

"  Berthenson. — Deut.  Vierteljahrschf.t.  f.   oflfentl.    Gesundheitspflege,    1898,  Vol.   XXX, 
page  315- 

20  Dorendorff. — Miinch.  med  Wchschft.,  1901,  Vol.  XL VIII,  page  236. 

21  Zellner  and  Wolff. — Ztschft.  f.  Hyg.  u.  Infectionskrankh.,  1913,  Vol.  LXXV,  page  69. 

2^  Chassevent    and    Garnier. — Arch.    Internal,  de    Pharmacodynamie    et    de    Therapie, 

1905,  Vol.  XIV,  page  93. 
-'  Agasse-Lafont    and    Heim. — Recherches   sur   I'Hygiene    du  Travail  Industrial.,  Paris, 

1912,  page  83. 
"  Santesson.— Arch.  f.  Hyg.,  1897,  Vol.  XXXI,  page  336. 
25  Selling. — Bull.  Johns  Hopkins  Hosp.,  1910,  Vol.  XXI,  page  s^. 
2^  Simonin, — Soc.  med.  d.  Hop.  d.  Paris,  1903,  Vol.  XX,  page  199. 
-'  K.  K.  Gewerbe-Inspectoren,  191 1,  page  490. 
2^  Lenoir  and  Claude. — Soc.  med.  d.  Hop.  d.  Paris,  Oct.  20,  1897. 


SECTION  IX 
CHRONIC  PHOSPHORUS  POISONING 

BY  ALICE  HAMILTON,  M.  D.,  Chicago.  IlL 

Industrial  phosphorus  poisoning  is  always  chronic.  It  may  occur  in 
chemical  works  where  phosphorus  is  obtained  from  mineral  phosphates,  or 
in  the  manufacture  of  matches  from  white  phosphorus,  or  in  the  use  of 
phosphor  bronze,  or  through  exposure  to  the  fumes  from  ferrosilicon,  or 
possibly  through  the  use  of  acetylene  gas  in  which  phosphorus  is  contained 
as  an  impurity. 

In  recovering  phosphorus  from  mineral  phosphates,  the  process  is  carried 
on  under  cover  to  hold  in  the  fumes,  and  the  phosphorus  collected  and  kept 
under  water.  The  work  is,  therefore,  almost  free  from  danger,  yet  there  are  a 
few  records  of  cases  of  phosphorus  necrosis  in  this  industry.  Pieraccini^  says 
that  the  preparation  of  phosphorus  from  calcined  bones  in  Italy  is  attended 
with  danger  of  necrosis.  The  British  report^  on  phosphorus  poisoning  states 
that  in  the  one  large  English  factory  where  phosphorus  is  prepared  from 
apatite  there  have  been  17  cases  scattered  over  a  period  of  50  years.  In 
France'^  nine  have  been  reported  from  the  chemical  works  since  1880. 

Ferrosilicon  is  used  in  the  manufacture  of  steel.  It  is  an  alloy  of  iron  and 
silicon,  the  latter  being  present  in  proportions  of  15  to  95  per  cent,  and  con- 
taining arsenic  and  phosphorus  as  impurities.  In  the  presence  of  moisture 
ferrosilicon  which  has  less  than  30  per  cent,  or  more  than  70  per  cent,  of 
silicon  decomposes,  giving  oflF  arsiniuretted  and  phosphuretted  hydrogen. 
Fatal  poisoning  has  occurred  from  these  fumes,^  chiefly  on  ships  which  were 
carrying  a  cargo  of  ferrosilicon  and  in  which  steerage  passengers  were  housed 
in  ill-ventilated  cabins  near  the  hold.  Such  cases  cannot  be  regarded  as  of 
industrial  origin,  but  they  serve  as  a  warning  that  the  use  of  ferrosilicon  in 
industry  is  not  free  from  dafiger. 

Phosphor  bronze  is  an  alloy  of  copper,  tin,  and  a  small  amount  of  phos- 
phorus, which  should  not  exceed  2  or  3  per  cent.  Kaup^  has  found  cases  of 
phosphorus  necrosis  in  Austria  where  phosphor  bronze  is  used  in  the  making 
of  cannon  and  of  cartridges.  His  attention  was  first  called  to  this  danger  by 
a  case  which  occurred  in  1897,  and  he  found  that  the  man  had  been  working 
with  an  alloy  consisting  of  copper  90  per  cent.,  tin  8.9  per  cent.,  and  phos- 
phorus 0.76  per  cent.  From  so  small  a  quantity  as  this,  phosphuretted 
hydrogen  was  given  off  in  amount  sufficient  to  cause  poisoning. 

Another  source  of  phosphorus  poisoning  in  the  United  States  was  recently 
uncovered  in  New  Jersey.     Miss  Lilian  Erskine,  of  the  New  Jersey  Depart- 
10  I4S 


146  OCCUPATIONAL   INTOXICATIONS 

ment  of  Labor,  is  authority  for  the  statement  that  in  the  making  of  fireworks 
in  that  state  a  paste  of  white  phosphorus  may  be  used  and  in  such  a  way  as 
to  expose  the  men  and  girls  employed  in  certain  departments  to  the  fumes  of 
phosphorus  and  to  direct  contact  with  the  paste.  The  method  is  said  to  have 
been  brought  over  to  this  country  from  Italy. 

A  possible  source  of  phosphorus  poisoning,  according  to  v.  Jaksch,®  is 
acetylene  gas  which  contains  this  element  as  an  impurity,  and,  according  to 
Holzer,^  the  use  of  phosphorus  in  the  making  of  miners'  lamps. 

All  these  industries  are  of  little  importance  compared  with  the  making  of 
phosphorus  matches,  which  is  the  phosphorus  trade  par  excellence,  employ- 
ing as  it  does  many  more  work-people  than  all  the  others  put  together.  The 
first  description  we  have  of  industrial  phosphorus  poisoning  was  written  12 
years  after  the  invention  of  lucifer  matches.  Lorinser,^  an  Austrian  physi- 
cian, wrote  in  1845  concerning  22  cases  of  necrosis  which  had  occurred  in  the 
match  factories  near  Vienna.  The  first  recorded  case  in  America  is  probably 
to  be  found  in  the  books  of  the  Massachusetts  General  Hospital  in  Boston 
for  1 85 1.  This  was  a  man  48  years  of  age,  who  for  14  years  had  been  em- 
ployed in  paste  making  and  in  dipping  matches.  He  had  no  symptoms  point- 
ing to  phosphorus  poisoning  till  18  months  before  his  admission  to  the 
hospital,  when  he  had  had  pain  in  one  of  the  lower  incisors  and  soon  after 
lost  the  tooth.  The  record  describes  a  stage  of  necrosis  already  far  advanced, 
with  swollen^  lower_Jaw,  bloated^  face,  eyes  dull  and  staring,  breath  very 
offensive  and  half  a  dozen  fistulous  openings  along  the  lower  border  of  the 
jaw.  The  upper  jaw  was  also  affected.  Later  entries  show  extension  of  the 
disease  and  increasing  toxaemia  ending  in  death  some  6  months  after  his  first 
admission.  Lorinser's  work  was  followed  during  the  next  few  years  by  pub- 
lications on  the  subject  of  phosphorus  necrosis  in  Germany,  France  and 
England,  and  from  that  time  up  to  the  present  day  no  year  has  passed  with- 
out a  large  number  of  reports  as  to  the  prevalence  and  the  prevention  of 
this  disease. 

It  is  the  most  dreaded  of  all  the  industrial  diseases,  not  because  it  is  the 
most  dangerous,  for  the  mortality  is  only  15  to  20  per  cent.,  nor  because  it  is 
widespread,  for  in  this  respect  it  does  not  compare  with  lead  poisoning,  nor 
because  it  is  sure  in  its  action,  for  in  reality  only  a  small  minority  of  those 
exposed  are  ever  affected,  but  because  of  the  great  and  prolonged  suffering 
caused  by  the  local  disease  and  the  shocking  deformities  which  almost  always 
result.  The  mere  fact  that  phosphorus  attacks  the  bones  of  the  face  and 
makes  its  effects  visible  in  pitiable  disfigurement  has  probably  had  much  to 
do  with  the  vigorous  efforts  which  have  been  made  to  do  away  with  this 
industrial  disease. 

In  the  making  of  matches  three  kinds  of  phosphorus  may  be  used,  but  the 
only  one  which  concerns  us  is  the  white  or  yellow,  the  amorphous  and  the 
sesquisulphide  not  being  dangerous.  Workers  in  white  phosphorus  match 
factories  make  the  paste,  dip  the  sticks  in  the  paste,  carry  the  matches  to 


CHRONIC   PHOSPHORUS   POISONING  I47 

drying  rooms,  carry  them  from  drying  to  packing  rooms,  and  pack  them  in 
boxes.  All  these  processes  are  attended  with  danger  from  the  fumes  of 
phosphorus,  especially  the  first  two. 

According  to  T.  E.  Thorpe,-  phosphorus  exposed  to  air  at  ordinary  tem- 
perature volatilizes,  forming  fumes  which  consist  of  phosphorous  oxide, 
about  5.8  per  cent.;  phosphoric  oxide,  73.1  per  cent.;  and  phosphorus,  21 
per  cent.  Thorpe  found  that  these  fumes  have  a  solvent  action  on  human 
teeth,  for  carious  teeth  exposed  to  phosphorus  for  12  hours  lose  0.37  per 
cent,  of  their  weight.  Fumes  dissolved  in  the  saliva  also  have  a  solvent 
action  on  the  teeth.  Dilute  phosphoric  acid  was  allowed  to  flow  over  frag- 
ments of  broken  teeth  for  3  hours  and  at  the  end  of  this  time  8.9  per  cent. 
of  their  weight  was  lost. 

Thorpe's  analysis  of  samples  of  air  in  a  match  factory  showed  that  at  a 
dipping  table  covered  with  phosphorus  paste  there  was  0.02  mg.  of  phos- 
phorus per  100  liters  of  air,  and  in  the  middle  of  the  boxing  rooms,  0.12  mg. 
per  100  liters.  An  analysis  of  the  water  in  which  the  workers  had  washed 
their  hands  after  4  hours'  work  showed  an  average  of  4.2  mg.  per  head  for 
a  day  of  10  hours. 

Pathology  and  Symptomatology. — Industrial  phosphorus  poisoning  is  a 
chronic,  local  dis^ease,  the  so-called  phosphorus  necrosis  or  "phossy  jaw." 
Usually  it  has  its  starting  place  in  a  carious  tooth,  or  perhaps  in  a  root  ex- 
posed by  receding  gums.  It  is  essentially  a  periostitis  of  the  alveolar  process 
of  one  or  the  other  maxilliry  bones,  resulting  in  the  formation  of  abscesses, 
sloughing  of  the  periosteum  and  necrosis  of  the  denuded  bone. 

The  first  symptom  is  a  toothache,  increasing  in  severity.  If  it  is  neglected 
pus  forms  under  the  periosteum  and  before  it  finds  an  outlet  the  pain  is 
excruciating.  Extraction  of  the  tooth  lays  bare  a  wound  filled  with  offensive 
pus,  and  it  is  characteristic  of  this  form  of  poisoning  that  the  extraction 
wound  should  be  very  slow  to  close.  If  before  healing  is  complete  the  patient 
goes  back  to  work,  the  opening  does  not  heal  and  the  inflammation  spreads, 
the  periosteum  is  loosened  and  sloughs  off  and  the  exposed  bone  undergoes 
necrosis.  If  the  lower  jaw  is  the  one  affected  an  active  proliferation  of  peri- 
osteum and  formation  of  callus  goes  on  along  the  margins  of  the  destructive 
process,  and  the  jaw  looks  thick  and  prominent,  but  in  the  upper  jaw  there  is 
little  effort  at  repair.  The  necrosed  bone  comes  away  from  the  upper  jaw 
in  fragments,  while  in  the  lower  a  sequestrum  forms  which  is  held  fast  by 
the  callus  and  is  not  spontaneously  cast  off. 

The  primary  effect  of  phosphorus  poisoning  is  a  change  in  the  periosteum 
making  it  less  resistant  to  infection;  the  secondary  effect  is  the  entrance  of 
pyogenic  organisms  through  a  cavity  or  a  defect  in  the  mucous  membrane  of 
the  mouth  and  the  setting  up  of  suppuration,  first  in  the  alveolar  periosteum 
and  in  the  gums,  later  in  the  surrounding  tissues.  The  late  symptoms  of 
phosphorus  poisoning  are  chiefly  the  symptoms  of  suppurative  disease. 

As  the  pus  which  has  formed  at  the  root  of  the  tooth  burrows  its  way  to 


148  OCCUPATIONAL   INTOXICATIONS 

the  surface  and  discharges,  there  is  relief  from  the  severest  pain,  but  the 
fistulous  openings  thus  formed  are  very  slow  to  heal  and  may  continue  to 
discharge  pus  for  months  or  even  years.  If  the  disease  is  in  the  upper  jaw  the 
fistulae  tend  to  pass  down  into  the  mouth,  but  when  it  is  in  the  lower,  the  pus 
works  its  way  down  and  breaks  through  the  cheek  or  neck.  There  may  be 
ulceration  of  the  lining  of  the  nose.  Ropke^  found  in  a  factory  in  Solingen 
19  out  of  64  workmen  with  ulceration  of  the  nostrils,  and  in  two  perforation 
of  the  septum  had  already  taken  place. 

In  the  majority  of  cases  healing  takes  place  after  a  year  or  two  with  the 
loss  of  several  teeth  and  a  part  of  the  alveolar  process,  but  in  other  cases  the 
destruction  is  much  more  extensive,  leading  to  loss  of  large  portions  or  even 
the  whole  of  the  lower  or  upper  jaw  bone.  In  the  worst  cases  both  upper  and 
lower  jaws  must  be  removed.  Andrews^"  reports  such  a  case  from  an  American 
factory,  the  man  being  able  to  take  only  liquid  food  afterward  till  his  death 
2  2  years  later.  Suppuration  may  extend  to  the  bones  of  the  face  and  cranium, 
or  to  the  orbit,  destroying  the  eye,  as  in  one  of  Andrews'  cases  and  in  two 
reported  by  Teleky.^^  When  the  disease  is  in  the  upper  jaw  there  is  danger  of 
extension  to  the  meninges,  an  accident  which  always  ends  in  death. 

Phosphorus  poisoning  is  typically  slow  in  onset.  Oliver's^^  cases  had 
worked  from  7  to  15  years  when  necrosis  developed.  Lewy's^*  82  cases  aver- 
aged 6.6  years'  exposure;  Hirt's  87,  5  years. ^*  Teleky^^  gives  his  record  as 
follows:  3  employed  less  than  i  year;  47  from  i  to  5  years;  41  from  6  to 
10  years;  41  from  11  to  20  years,  and  13  more  than  20  years.  Yet  there  are 
some  unusually  rapid  cases,  especially  among  youthful  workers.  Lorinser* 
had  one  which  followed  7  weeks'  exposure.  Garman,^^  who  was  for  many 
years  physician  to  a  large  English  match  factory,  saw  nine  fatal  cases,  all 
dying  at  an  early  age:  two  were  19  years  old,  one  was  21,  three  were  22,  one 
was  23,  and  two  were  27. 

The  lower  jaw  is  said  to  be  affected  in  about  60  per  cent,  of  all  cases. 
Telekyii  and  Hirt  both  found  the  proportion  to  be  five  of  the  lower  to  three  of 
the  upper.  Villaret,^^  however,  found  the  upper  oftener  involved  and  so 
did  Kuipers.^'^     Garman^^  found  the  numbers  practically  equal. 

Apparently  sex  does  not  play  any  part  in  influencing  susceptibility  to 
phosphorus  poisoning.  The  majority  of  cases  in  recent  years  have  been 
among  men,  because  the  most  dangerous  work,  mixing  and  applying  the  paste, 
was  done  by  men,  while  the  women  had  the  safer  work  of  packing.  Teleky^^ 
had  but  8;^  cases  among  women  to  139  among  men,  though  there  are  four  or 
five  times  as  many  women  as  men  in  the  Austrian  factories. 

It  is  a  disease  of  long  duration,  lasting,  under  treatment,  usually  from 
I  to  2  years  but  often  much  longer,  and  when  recovery  does  take  place  it  is 
rarely  complete,  for  the  new  bone  is  not  sufficient  for  real  repair  and  the  sink- 
ing in  of  the  soft  parts,  together  with  the  scars  from  healed  abscesses  and 
fistulae,  result  in  terribly  disfiguring  deformities. 

The  mortality  under  modern  treatment  is  from  15  per  cent,  to  20  per  cent. 


CHRONIC   PHOSPHORUS    POISONING  1 49 

When  death  occurs  early  in  the  course  of  the  disease,  it  is  from  sepsis  or 
meningitis;  when  later,  it  may  be  from  the  cachexia  of  chronic  sepsis  or  from 
tuberculosis.  Chronic  digestive  disturbances  contribute  to  lowering  of  the 
vitality  and  are  due,  at  least  in  part,  to  the  continual  discharge  of  pus  into 
the  mouth  in  cases  with  prolonged  suppuration. 

Individual  susceptibility  is  an  important  factor  in  this  form  of  poisoning, 
for  only  a  very  small  minority  of  those  exposed  ever  develop  necrosis,  even 
of  those  with  carious  teeth.  The  same  thing  is  found  to  be  true  of  animals 
exposed  to  phosphorus  fumes;  only  a  few  succumb.  No  absolutely  complete 
statistics  are  to  be  found  as  to  the  occurrence  of  phosphorus  poisoning 
among  match  workers,  but  the  following  are  fairly  so:  Hirt^*  reported  70 
cases  during  20  years  among  600  workmen  in  the  Silesian  factories;  Magitot^* 
gives  nearly  the  same  figures  for  the  French  factories,  70  in  21  years  among 
620  workers.  The  British  report  of  1896^  states  that  among  1701  persons 
employed  in  occupations  exposing  them  to  the  fumes  of  phosphorus  were 
300  men  who,  during  the  preceding  5  years,  had  had  16  cases  of  necrosis,  and 
1 401  women  who  had  had  14  cases,  making  30  cases  in  5  years  among  1701 
persons. 

There  has  long  been  a  controversy  as  to  whether  phosphorus  poisoning 
is  to  be  regarded  as  a  purely  local  or  a  systemic  disease.  The  earlier  writers, 
especially  the  French,  considered  it  a  general  poison  invading  all  the  tissues 
and  manifesting  itself,  even  in  the  absence  of  necrosis,  by  general  cachexia, 
anaemia,  respiratory  disease,  dyspepsia,  albuminuria,  and  even  paralysis. 
To  this  condition  Magitot^*  gave  the  name  "phosphorisme,"  and  he  believed 
that  the  phosphorus  worker  may  keep  on  for  years  without  evidences  of 
poisoning  so  long  as  his  functional  equilibrium  is  maintained,  but  if  there  be 
an  injury  to  the  mouth,  such  as  the  drawing  of  a  tooth,  the  disease  will  be- 
come active.  He  therefore  advised  an  expectant  treatment  as  long  as  possi- 
ble. Pieraccini^  thinks  that  though  necrosis  is  rare,  it  is  a  mistake  to  con- 
clude that  therefore  phosphorus  poisoning  is  rare,  for  general  phosphorisme 
may  exist  without  necrosis. 

On  the  other  hand,  the  physicians  appointed  by  the  French  Government^ 
to  inquire  into  the  health  of  match  workers  found  no  evidence  of  general 
ill  health.  Mahu^^  says  that  among  tobacco  workers  7  out  of  11  deaths 
are  caused  by  tuberculosis,  but  among  match  workers  only  5  among  15. 
The  British  report  to  the  House  of  Lords^  states  that  there  is  little  if  any 
phosphorisme  among  these  people  in  England,  and  Oliver  has  seen  necrosis 
in  strong  and  otherwise  healthy  people.  According  to  Helbig,-"  the  German 
factory  inspectors  usually  report  the  general  health  of  match  makers  to  be 
good. 

That  phosphorus  has  a  specific  action  upon  the  bony  system  in  general 
is,  however,  not  denied.  Long  exposure  to  the  fumes  of  phosphorus  seems 
to  set  up  changes  in  the  periosteum  of  other  bones  than  those  of  the  jaws, 
making  it  more  vulnerable,  less  resistant  to  infection.     The  most  significant 


150  OCCUPATIONAL   INTOXICATIONS 

case  of  this  kind  is  Wegner's^^  reported  in  1872.  A  man  of  19  years  had 
recently  left  the  match  factory  in  which  he  had  worked  since  he  was  4  years 
old  without  any  symptoms  of  poisoning  either  local  or  general.  He  was 
injured  by  the  wheel  of  a  wagon  passing  over  his  leg  and  received  two  flesh 
wounds  not  extending  to  the  bone.  Gangrene  set  in  necessitating  an  ampu- 
tation above  the  knee-joint,  during  which  it  was  discovered  that  the  perios- 
teum of  the  femur  was  loosened  and  dead  bone  protruded  from  the  wound. 
The  destruction  of  periosteum  increased,  extending  up  the  thigh,  and  the 
man  died  of  sepsis  on  the  sixth  day.  Wegner  found  at  autopsy  a  slight  gen- 
eral hyperostosis  of  the  cranial  bones,  an  ossifying  periostitis  of  the  alveolar 
processes  of  both  jaws,  and  bony  deposits  on  the  epiphyses  of  the  long  bones. 

The  experiments  which  Wegner  made  on  animals  showed  that  under  the 
influence  of  phosphorus  fumes  there  occurs  a  thickening  of  the  subperiosteal 
bone  at  the  expense  of  the  Haversian  canals,  narrowing  them  and  thus  par- 
tially shutting  off  the  vascular  supply  to  the  bone.  Layers  of  very  compact 
tissue  are  laid  down  in  the  region  of  the  epiphyseal  cartilages.  In  the  jaw 
bones  there  is  an  enormous  thickening  of  the  periosteum  and  so  much  sweUing 
of  the  soft  parts  that  the  animal  can  no  longer  open  its  mouth.  Necrosis 
with  softening  and  sloughing  is  found  only  when  there  has  been  an  injury 
to  the  mucous  membrane  leading  down  to  the  bone.  The  same  fact  was 
established  by  the  earlier  experiments  of  v.  Bibra  and  Geist.''  It  is  only 
exposure  to  fumes  that  sets  up  these  changes  in  animals;  feeding  them  phos- 
phorus has  no  such  effect. 

Twenty  years  after  Wegner,  Riche^^  discussed  these  experiments  and 
pointed  out  the  bearing  which  later  studies  in  bacteriology  have  had  on  our 
conception  of  phosphorus  necrosis.  The  osseous  changes,  Riche  said,  were 
attributable  to  phosphorus,  but  the  necrosis  was  caused  by  the  action  of 
microorganisms  on  this  changed  tissue.  Phosphorus  produces  changes  in 
all  the  bones,  but  necrosis  takes  place  in  the  bones  of  the  jaw  because  they, 
more  than  any,  are  exposed  to  the  entrance  of  pus-forming  bacteria.  Teleky-- 
also  emphasizes  the  importance  of  the  secondary  effect  of  pyogenic  organisms 
in  the  case  of  phosphorus  necrosis  and  believes  that  a  careful  examination  of 
the  histories  of  patients  with  so-called  phosphorisme  would  show  that  the 
cachexia  was  due  to  chronic  sepsis  or  to  tuberculosis. 

The  effect  of  phosphorus  on  the  periosteum  in  lowering  its  resistance  to 
infection  is  seen  in  those  cases  of  which  there  are  several  in  the  literature 
in  which  the  necrosis  developed  long  after  the  person  had  left  the  atmosphere 
of  phosphorus  fumes.  In  the  French  factory  at  Trelaze^  the  use  of  white 
phosphorus  was  discontinued  in  1894,  but  3  years  later  a  pronounced  case 
of  necrosis  developed,  V.  Bibra  and  Geist^  reported  the  case  of  a  23-year-old 
girl  who  worked  a  few  years  in  a  match  factory  and  felt  no  ill  effects  except  an 
occasional  toothache.  A  year  after  she  left  the  factory  she  was  seen  by  the 
authors  and  was  then  in  an  indescribably  terrible  condition,  dying  of  sepsis. 

Another  evidence  of  alteration  in  the  bones  as  a  result  of  phosphorus 


CHRONIC   PHOSPHORUS   POISONING  151 

fumes  is  found  in  an  abnormal  fragility  of  the  long  bones  which  fracture 
as  a  result  of  a  slight  injury  or  even  of  muscular  action  only.  This  "  fragilitas 
ossium"  has  been  reported  by  several  French  writers,  by  Brocoorens  in 
Belgium,^  by  Kocher  in  Berne,^  by  Teleky  in  Austria/^  by  Garman^'  in 
England,  and  by  Andrews^"  in  America. 

Treatment. — It  is  still  a  matter  of  controversy  whether  the  treatment  of 
necrosis  should  be  early  and  radical  or  expectant  and  conservative.  Some 
dentists  advise  the  extraction  of  all  carious  teeth  if  the  person  has  been  work- 
ing in  a  match  factory;  others  prefer  to  fill  those  that  are  in  the  first  and  sec- 
ond stages  of  caries.  In  either  case  there  is  no  question  that  the  patient  must 
be  forbidden  to  return  to  the  factory  till  the  mouth  is  in  a  sound  condition. 
When  the  pulp  is  exposed,  extraction  is  imperative  and  the  resulting  wound 
must  receive  careful  treatment  till  it  is  healed.  Abscesses  must  be  freely 
incised,  cleaned  and  drained.  When  necrosis  of  the  bone  has  taken  place 
there  are  many  who  advise  immediate  subperiosteal  resection  through  healthy 
bone.  Kocher-  foUows  this  plan  and  claims  83.7  per  cent,  of  cures.  Kuipers^'^ 
has  had  89.0  per  cent,  by  the  same  method,  while  Garman^^  waits  for  a 
sequestrum  to  form  before  he  operates  and  claims  that  he  has  83.0  per  cent, 
cured.  Teleky^^  has  lately  come  out  for  the  expectant  treatment.  He 
believes  that  the  early  resection  of  large  parts  of  the  jaw  has  seemed  to  give 
good  results  largely  because  the  relapses  have  not  come  under  the  observation 
of  the  surgeon.  In  order  to  bring  about  healing  in  such  an  early  operation, 
it  is  necessary  to  remove  a  much  larger  portion  of  bone  than  if  one  waits  for 
the  formation  of  a  sequestrum.  This  does  prolong  the  disease,  but  results 
in  less  deformity  and  less  disturbance  of  function.  Therefore  unless  the 
disease  is  too  protracted  or  the  danger  of  sepsis  too  great  he  advises  against 
early  extensive  operation. 

Preventive  Measures. — The  prevention  of  phosphorus  necrosis  has  been 
shown  to  depend  absolutely  on  the  prevention  of  the  manufacture  of  white 
phosphorus  matches.  The  history  of  the  match  industry  in  Europe,  in  Great 
Britain  and  in  our  own  country  shows  that  years  of  preventive  work  through 
the  removal  of  fumes,  the  substitution  of  machinery  for  hand  work,  and  the 
medical  and  dental  care  for  the  workers  have  been  unsuccessful,  for  cases 
of  necrosis  have  continued  to  appear  even  in  the  best-managed  factories. 
Phosphorus  necrosis  does  not  disappear  so  long  as  white  phosphorus  is  used 
in  industry.  France  has  had  the  longest  experience  in  the  making  of  non- 
poisonous  matches  and  Leclerc  de  Pulligny-"*  reports  that  since  1898,  when 
the  use  of  white  phosphorus  was  finally  given  up  in  all  the  State  factories,  the 
special  precautions  which  were  formerly  used  have  also  been  given  up,  but 
no  case  of  phosphorus  necrosis  has  occurred. 

REFERENCES 

'  Pieraccini. — Patologia  del  Lavoro,  Milan,  1906. 

2  Sessional  Papers  of  the  House  of  Lords,  1899,  Vol.  LXXII;  T.  E.  Thorpe,  Thomas  Oliver, 
and  George  Cunningham. 


fc 


152  OCCUPATIONAL   INTOXICATIONS 

'  Poisons  Industrielles.     Office  du  Travail,  Republique  Francaise  Paris,  1901,  Imprimerie 
Nationale. 

*  Glaister. — Industrial  Poisoning  by  Gases  of  Arsenic  and  Phosphorus.     Internal.  Congr. 
Industrial  Hygiene,  Brussels,  1910. 

^  Kaup. — Bauer's  Gesundheitsgefahrliche  Industrien,  Jena,  1903,  page  119. 

^  Von  Jaksch.- — Die  Vergiftungen,  Vienna,  1910. 

^  Holzer. — Bauer's  Gesundheitsgefahrliche  Industrien,  Jena,  1903,  page  i. 

8  Lorinser. — Quoted  by  Holzer. 

^  Ropke. — Concordia,  1901,  Vol.  VIII,  page  18. 
^^  Andrews. — Bulletin  86,  U.  S.  Bureau  of  Labor. 
^^  Teleky. — Handworterbuch    d.    sozialen    Hygiene.     Edited    by    Grotjahn    and    Kaup, 

Leipzig,  191 2. 
^2  Oliver. — Dangerous  Trades,  London,  1902. 
^^  Lewy. — Quoted  by  Holzer. 
^*  Hirt. — Quoted  by  Holzer. 

1*  Garman. — Quoted  by  Oliver  in  Sessional  Papers. 
16  Villaret.— Quoted  by  Helbig. 
1^  Kuipers. — Inaug.  Dissert.,  Jena,  1895. 
18  Magitot. — Quoted  by  Holzer. 
1^  Mahu. — Quoted  in  Sessional  Papers. 

20  Helbig.— Weyl's  Hb.  d.  Hyg.,  Vol.  VIII,  page  766. 

21  Wegner. — Virch.  Arch.,  1872,  Vol.  LV,  page  ii. 

22  Teleky. — Weyl's  Hb.  d.  Gewerbehyg,  Jena,  1908,  page  227. 

2'  Riche. — Gaz.  des  Hop.  civils  et  milit.     Paris,  1892,  Vol.  LXII,  page  1109. 
2*  Leclerc  de  PuUigny,  quoted  by  Bauer,  page  204. 


SECTION  X 
THE  PREVENTION  OF  PHOSPHORUS  POISONING 

BY  JOHN  B.  ANDREWS,  Ph.  D..  New  York  City,  N.  Y. 

Phosphorus  poisoning  arises  in  the  extraction  of  phosphorus,  in  the 
production  of  phosphorus  compounds,  such  as  igniting  agents,  in  the  extrac- 
tion of  coal-tar  dyes,  in  the  making  of  phosphor-bronze,  and  in  the  manu- 
facture of  matches.  In  America,  as  elsewhere,  the  last-named  industry  has 
been  the  main  source  of  the  disease. 

White  or  yellow  phosphorus  was  discovered  in  1669  by  Brand,  of  Ham- 
burg, while  he  was  experimenting  for  a  liquid  to  transform  silver  into  gold. 
It  is  now  obtained  commercially  by  treating  bone  ash  with  sulphuric  acid, 
filtering  and  evaporating  the  product,  heating  this  with  charcoal,  and  after- 
ward distilling  it.  It  is,  when  pure,  a  colorless,  transparent,  crystalline 
substance,  which  readily  becomes  yellow  upon  exposure  to  light.  It  is  vola- 
tile at  ordinary  air  temperature,  and  in  addition  to  its  poisonous  quahties 
is  highly  inflammable. 

The  ignition  of  phosphorus  by  friction  was  discovered  in  1680,  but 
although  the  first  friction  match  was  invented  in  England  by  John  Walker 
in  1827,  it  was  not  until  1833  or  thereabouts  that  phosphorus  was  utilized 
in  the  composition  of  match  heads,  in  Vienna.  In  1836  the  first  American 
patent  for  a  friction  match  was  granted  to  Alonzo  Phillips,  of  Springfield, 
Massachusetts,  and  in  1842  Reuben  Partridge  invented  the  first  splint- 
cutting  machine.  From  that  time  to  the  present  the  principal  inventions 
of  machines  in  this  industry  have  been  made  by  Americans. 

Three  kinds  of  phosphorus  are  now  used  in  match  manufacture,  to  which 
correspond  three  types  of  matches. 

One  is  the  "safety  match,"  which  must  be  struck  on  a  prepared  surface. 
This  match  contains  no  phosphorus  and  is  harmless.  The  igniting  composi- 
tion is  painted  on  the  box  and  contains  the  red  or  amorphous  phosphorus 
discovered  by  Schrotter  in  1845,  which  is  made  by  baking  the  poisonous 
white  or  yellow  variety  in  a  closed  vessel,  and  is  consequently  more  expensive. 
The  red  phosphorus  is  insoluble  in  the  human  digestive  tract,  and  when  pure 
is  therefore  non-poisonous.  Although  used  almost  exclusively  in  one  or 
two  countries  of  Europe,  the  manufacture  of  "safety"  matches  is,  in  America, 
still  very  limited. 

The  second  kind  of  match — the  familiar  old-style  "strike  anywhere" 
parlor  match — is  now  happily  fast  disappearing.  The  match  can  be  struck 
on  any  ordinary  rough  surface,  but  possesses  the  disadvantage  that  the  paste 

153 


154  OCCUPATIONAL   INTOXICATIONS 

used  for  the  heads  contains  from  5  to  7  per  cent,  of  poisonous  phosphorus, 
the  other  ingredients  being  glue,  powdered  glass,  oxide  of  zinc,  chlorate  of 
potassium,  and  some  coloring  mixture.  To  the  presence  of  the  poisonous 
phosphorus  can  be  traced  the  phosphorus  necrosis  among  workers  in  match 
factories.  The  use  of  this  poisonous  element  in  match  manufacture  is  now 
prohibited  in  the  leading  countries  of  the  world,  including  the  United  States 
where  this  result  was  accomplished  through  the  imposition  of  a  prohibitive 
tax.  An  older  form  of  the  phosphorus  match  is  the  sulphur  or  card  match, 
so  named  on  account  of  the  sulphur  in  the  head  and  the  card  form  in  which 
the  matches  were  sold.  Due  to  the  disagreeableness  of  the  sulphur  fumes 
this  match  has  fallen  into  almost  complete  disuse. 

The  third  variety  of  match  also  possesses  the  desirable  quality  of  striking 
anywhere  and  is  at  the  same  time  non-poisonous.  This  is  the  strike  any- 
where match  now  manufactured  and  used  in  those  countries  where  public 
sentiment  has  been  sufficiently  aroused  to  prohibit  the  use  of  white  phos- 
phorus. In  France,  where  the  substitute  for  white  phosphorus  was  dis- 
covered and  where  it  was  first  used,  the  match  business  has  been  a 
government  monopoly  for  more  than  25  years,  and  as  such  threw  upon  the 
government  the  burden  of  the  human  loss  resulting  from  the  peculiar  haz- 
ards of  the  industry.  Government  officials  noticed  that  the  profit  they  had 
hoped  to  receive  from  the  business  was  rapidly  drawn  away  in  the  form  of 
compensation  for  sickness  and  death  from  phosphorus  poisoning.  Experts 
were  set  to  work  and  in  1898  Sevene  and  Cohen  found  a  substitute  for  the 
poisonous  element,  in  the  sesquisulphide  of  phosphorus.  This  substitute 
has  not  only  been  successfully  employed  in  France  but  has  been  introduced 
almost  everywhere  where  white  phosphorus  is  forbidden. 

Although  complicated  by  modern  methods  and  machines,  the  fundamental 
processes  in  the  manufacture  of  matches  may  be  described  in  a  few  words: 
The  wooden  match  splint  is  prepared;  the  phosphorus  composition  for  the 
head  of  the  match  is  mixed;  one  end  of  the  splint  is  dipped  into  the  paste; 
the  "green"  match  is  allowed  to  dry;  and  finally  it  is  boxed  and  wrapped. 

The  lumber  from  which  match  splints  are  made  is  usually  poplar  or 
basswood.  White  pine  makes  the  best  splints,  but  it  is  hard  to  get.  Blocks 
which  have  been  selected  so  as  to  be  free  from  knots  and  of  a  certain  dimen- 
sion are  fed  into  the  machine  by  an  operative  called  a  "block  feeder."  The 
machinery  holds  the  block  against  knives,  which  cut  out  the  splints  and  force 
them  into  perforations  in  a  series  of  hinged  iron  plates  which  move  as  an 
endless  chain  over  the  entire  length  of  the  machine.  Projecting  from  the 
lower  surfaces  of  the  iron  plates,  the  splints  move  from  the  front  end  of  the 
machine  into  a  bath  of  melted  paraffine.  They  are  then  passed  over  a 
roller  which  is  coated  with  phosphorus  paste  by  running  in  a  trough  contain- 
ing the  composition,  which  trough  is  in  turn  supplied  by  a  pipe  leading  from 
a  covered  tank  on  the  machine  holding  a  supply  properly  heated.  This 
last  operation  puts  the  heads  on  the  matches.     The  finished  matches  are 


THE   PREVENTION    OF   PHOSPHORUS   POISONING  1 55 

now  ready  to  be  dried,  which  is  accomplished  by  the  movement  of  the  end- 
less chain  of  plates  over  a  series  of  drums,  bringing  them  during  their  transit 
in  contact  with  a  number  of  air  currents.  The  time  for  drying  varies  with 
the  weather,  but  usually  takes  an  hour.  Arriving  again  at  the  front  of  the 
machine,  the  matches  are  mechanically  punched  out  of  the  plates,  and  are 
then  handled  by  the  filling  mechanism,  passing  finally  to  a  revolving  table 
at  which  girls  are  seated  who  slide  the  covers  on  the  boxes. 

If  the  poisonous  variety  of  phosphorus  is  used,  practically  every  process 
in  this  series  following  the  preparation  of  the  splints  is  dangerous.  In  the 
mixing,  dipping,  drying  and  packing  rooms  the  danger  from  breathing 
phosphorus  fumes,  although  it  may  be  somewhat  diminished  by  thorough 
ventilation  and  by  the  rigid  enforcement  of  preventive  measures,  is  always 
present.  Particles  of  phosphorus  also  become  attached  to  the  hands  of  the 
employees  and  are  later  transferred  to  their  mouths. 

For  over  three-quarters  of  a  century  the  dangers  incident  to  the  use  of 
white  phosphorus  in  this  industry  have  been  known.  As  early  as  1838 
Doctor  Lorinser,  of  Vienna,  diagnosed  in  a  female  match  worker  named 
Marie  Jankovits  the  first  authentically  recorded  case  of  industrial  phosphorus 
poisoning.  The  rapid  reporting  of  additional  cases  led  the  Austrian  govern- 
ment to  appoint  a  committee  of  inquiry,  but  the  committee's  recommenda- 
tions apparently  never  became  effective,  for  in  the  10  years  1866  to  1875 
there  were  reported  126  cases  of  phosphorus  necrosis  in  the  hospitals  of 
Vienna  alone. 

The  death  of  a  match  maker  in  London  about  1896  and  the  consequent 
newspaper  discussion  of  unhealthful  conditions  in  the  trade  fixed  British 
attention  upon  industrial  phosphorus  poisoning.  A  total  of  105  cases,  19 
of  which  resulted  fatally,  were  reported  in  Great  Britain  up  to  the  end  of  1900, 
but  the  record  is  admittedly  incomplete.  While  in  Great  Britain  less  than  i 
per  cent,  of  match  makers  were  found  to  have  suffered  from  phosphorus 
necrosis,  in  Switzerland  it  was  formerly  1.6  to  3  per  cent.,  and  in  France  2  to 
3  per  cent. 

In  America  a  surgeon  published  as  early  as  1855  a  pamphlet  giving  the 
history  of  nine  serious  cases  of  phosphorus  poisoning  in  New  York  City. 
One  of  these  earliest  cases  required  the  removal  of  an  entire  jaw. 

In  1864,  IJ2  more  serious  cases  from  these  same  match  factories  were 
recorded  in  a  letter  to  the  New  York  Evening  Post.  At  that  time  there  were 
75  match  factories  scattered  throughout  the  eastern  states,  but  the  toll 
taken  by  phosphorus  from  these  many  establishments  is  unknown.  That 
phosphorus  necrosis,  however,  was  a  common  malady  25  years  ago  among 
match  factory  employees  in  this  country  is  not  denied  by  anyone. 

In  the  course  of  their  general  investigation  into  the  conditions  of  women 
and  child  wage-earners  in  1908  and  1909,  agents  of  the  United  States  Bureau 
of  Labor  found  16  definite  cases  of  phosphorus  poisoning  among  match 
factory  operatives,  and  learned  that  many  other  cases  had  occurred,  not  only 


156  OCCUPATIONAL   INTOXICATIONS 

many  years  before,  but  also  in  recent  years  and  in  some  of  the  factories  where 
conditions  were  the  best.  This  discovery,  and  the  related  activities  in  Euro- 
pean countries,  led  to  an  intensive  study  under  the  joint  auspices  of  the 
Bureau  and  of  the  American  Association  for  Labor  Legislation,  of  15  of 
the  16  match  factories  then  in  operation,  all  of  which  were  using  poisonous 
phosphorus.* 

The  15  factories  investigated  employed,  according  to  statements  by  the 
manufacturers,  3591  persons,  of  whom  2024  were  men,  and  1253  were 
women  16  years  of  age  and  over.  Children  under  16  numbered  314,  121 
boys  and  193  girls.  Detailed  investigation  showed  that  65  per  cent,  of  the 
employees  were  working  under  conditions  which  exposed  them  to  the  dangers 
of  poisoning.  The  women  and  children  were  much  more  exposed  than  the 
men,  95  per  cent,  of  the  women  and  83  per  cent,  of  the  children  under  16 
years  of  age  being  so  exposed. 

An  investigation  by  the  writer  in  the  homes  of  the  work-people  of  three 
of  these  factories  yielded  a  total  of  82  cases  of  phosphorus  poisoning.  In 
two  factories  at  least  eight  perfectly  authenticated  cases  were  found  to  have 
occurred  in  i  year,  and  references  were  obtained  to  three  more.  In  one 
small  factory  records  were  secured  of  more  than  20  serious  cases  during  the 
past  30  years,  many  of  them  requiring  the  removal  of  an  entire  jaw.  In 
one  of  the  most  modern  establishments,  records  of  40  cases  were  secured.  Of 
this  number  15  resulted  in  permanent  deformity  through  the  loss  of  one  or 
both  jaws,  and  several  cases  resulted  in  death.  In  another  factory  the  records 
of  21  cases  were  secured,  six  of  which  were  in  the  year  of  the  investigation. 
In  all,  the  records  of  over  150  cases,  of  which  four  were  fatal,  were  collected 
in  a  very  short  time,  although  it  had  been  the  claim  of  the  match  manufac- 
turers, and  there  was  a  popular  impression  to  the  effect,  that  the  trouble  had 
not  existed  in  this  country  in  a  serious  form  for  20  years. 

Preventive  Measures. — The  early  manufacture  of  matches  was  often 
carried  on  in  dirty  and  ill- ventilated  workrooms  which  exposed  the  employees 
to  every  danger  of  phosphorus  poisoning.  With  the  increasing  demand  for 
matches  conditions  grew  worse  until  within  1 1  years  after  the  phosphorus  match 
was  discovered,  government  investigators  in  Europe  were  studying  the  condi- 
tions which  brought  on  the  disease.  The  infant  industry  was  driven  out  of 
the  cellars.  The  rules  issued  by  the  various  governments  in  the  attempt  to 
"regulate"  the  effect  of  the  poison  upon  the  health  of  workers  included  such  pro- 
visions as  closed-in  machinery,  exhaust  and  ventilating  systems,  separate  lunch 
rooms,  dressing  rooms  and  wash  rooms,  with  mouth  wash  and  soap  and  towels 
furnished  by  the  employer,  medical  and  dental  inspection  at  the  expense  of 
the  employer,  and  factories  built  according  to  architectural  plans  furnished 
by  the  government.  The  hours  of  labor  were  also  strictly  regulated,  and 
women  and  children  were  rigidly  excluded  from  the  most  dangerous  depart- 

*Phosphoius  Poisoning  in  the  Match  Industry,  by  John  B.  Andrews,  Bulletin  86, 
United  States  Bureau  of  Labor. 


THE   PREVENTION   OF   PHOSPHORUS   POISONING  157 

ments.  The  percentage  of  phosphorus  in  the  paste  was  Hmited  until  many- 
manufacturers  rebelled  and  made  matches  in  defiance  of  the  laws.  Notices 
warning  employees  of  the  dangers  involved  in  the  handling  of  phosphorus 
were  posted,  and  employers  were  required  to  read  the  warnings  to  their 
employees  at  stated  intervals.  Partly  as  a  result  of  these  extraordinary 
and  expensive  precautions  the  industry  was  rapidly  concentrated  in  the 
hands  of  a  comparatively  few  employers  and  conditions  were  improved,  but 
wherever  special  study  was  made  phosphorus  poisoning  was  nevertheless 
found  to  exist  in  a  serious  form.  During  all  of  the  past  generation,  in  spite  of 
attempts  on  the  part  of  humane  employers  and  governments  to  regulate  the 
evil,  the  malady  continued  to  claim  its  victims  one  by  one.  So  serious  was 
the  situation  that  the  regulative  method  of  dealing  with  the  problem  gradually 
became  recognized  as  totally  inadequate. 

In  1872  Finland  gave  up  attempts  at  regulation  and  enacted  the  first  law 
prohibiting  the  use  of  white  phosphorus  in  match  factories.  Denmark,  in 
1874,  with  a  similar  experience,  did  the  same.  For  40  years  they  have  had 
no  cases  of  phosphorus  necrosis.  France  prohibited  the  poisonous  ingredient 
in  1897,  Switzerland  in  1898,  and  the  Netherlands  in  1901.  In  1906,  on  ac- 
count of  the  difficulties  of  eliminatiflg  the  use  of  phosphorus  in  countries 
with  an  important  export  trade,  the  International  Association  for  Labor 
Legislation  secured  an  international  conference  at  Berne  which  resulted  in  an 
international  convention  providing  for  the  absolute  prohibition  of  the  manu- 
facture, importation  or  sale  of  white  phosphorus  matches.  The  convention 
was  signed  by  Denmark,  France,  Germany,  Italy,  Luxemburg,  the  Nether- 
lands, and  Switzerland,  to  which  were  added  Great  Britain  in  1908  and  Spain 
in  1909,  together  with  numerous  colonies  of  the  signatory  states.  Without 
signing  the  convention,  Austria  enacted  a  prohibitory  law  in  1909,  New 
Zealand  and  New  South  Wales  did  so  in  1910,  Hungary  in  191 1,  Mexico  in 
1912  and  Canada  in  1914. 

In  the  United  States,  which  was  prevented  by  constitutional  limitations 
from  signing  the  convention  and  where  the  national  government  may  not 
regulate  directly  the  conditions  of  industry  within  the  states,  resort  was  had 
to  the  federal  taxing  power.  By  a  law  enacted  by  Congress  in  191 2,  to  go 
into  effect  on  July  i,  1913,  a  prohibitive  tax  of  2  cts.  a  hundred  was  levied  on 
matches  made  of  white  phosphorus.  Their  importation  and  exportation 
were  also  absolutely  forbidden  after  January  i,  1913,  and  January  i,  1914, 
respectively.  Heavy  penalties,  ranging  up  to  $5000,  or  imprisonment  for 
3  years,  or  both,  were  provided  for  violation  of  the  act. 

Thus  throughout  practically  the  whole  civilized  world,  before  the  close  of 
1914,  the  use  of  poisonous  phosphorus  in  the  manufacture  of  matches  has 
been  definitely  prohibited.  And  with  such  prohibition  there  was  abolished 
from  the  match  industry  that  most  loathsome  of  occupational  diseases, 
phosphorus  necrosis. 


CHAPTER  II 

OCCUPATIONAL  INFECTIOUS  DISEASES 

SECTION  I 

ANTHRAX 

BY  LANGDOX  FROTHIXGHAM,  M.  D.  V.,  Boston,  Mass. 

Synonyms. — English:  anthrax,  splenic  fever;  in  the  human  species, 
malignant  pustule,  wool  sorter's  disease,  rag-picker's  disease.  French: 
Charbon,  Fiebre  charbonneuse,  Charbon  bacteridien.  Italian:  Antrace, 
Febbre  carbonchiosa.     German:  Milzbrand,  Milzfieber,  Karbunkelkrankheit. 

The  Bacillus  anthracis  is  intimately  associated  with  the  history  of  bacterial 
infection.  Owing  to  its  large  size,  ease  of  cultivation,  rapidity  of  growth, 
and  the  facility  with  which  it  may  be  stained,  it  perhaps  has  been  and  is, 
more  frequently  employed  than  any  other  organism  for  morphological  and 
biological  study.  It  was  first  seen  microscopically  by  PoUender  in  1849  in 
the  blood  of  a  cow  that  had  died  of  anthrax.  It  was  later  observed  by  others 
and  in  1863  Davaine  showed  it  to  be  the  cause  of  the  disease.  It  was  there- 
fore the  first  bacterium  to  be  definitely  associated  etiologically  with  an  in- 
fectious disease  of  animals.  Its  artificial  cultivation  by  Koch  (1876)  and 
Pasteur  (1877)  established  a  new  line  of  thought  and  study  and  Pasteur's 
classical  experiments  in  attenuation  and  protective  inoculation  laid  the  basis 
of  subsequent  theories  of  immunity.  Therefore  it  has  been  well  claimed 
that  the  Bacillus  anthracis  is  the  very  "cornerstone"  of  modern  bacteriology. 

Morphology. — According  to  various  observers  the  anthrax  bacillus  varies 
in  length  1.5  to  10  //  and  in  width  from  i.o  to  2.5  ^t.  It  is  non-motile,  multi- 
plies by  direct  division  and  under  certain  conditions  by  spore  formation. 
For  example,  "spores  never  develop  in  the  tissue  fluids  of  the  living  animal, 
in  the  unopened  carcass,  or  inside  of  the  meat  of  slaughtered  animals" 
(Hutyra  and  Marek),  but  they  invariably  appear  when  the  organism  is  culti- 
vated on  artificial  media  and  are  also  formed  in  nature  under  proper  con- 
ditions of  heat  and  moisture.  The  spore  occurs  as  a  relatively  large  oval 
body  situated  in  the  center  of  the  bacillus.  The  bacilli  usually  appear  in 
shorter  or  longer  chains.  In  the  blood,  organs,  and  local  lesions,  such 
chains  are  composed  of  two  to  a  dozen  or  more  bacilli,  while  in  culture  media 
the  chains  are  frequently  so  long  that  the  number  of  individual  bacilli  cannot 
be  estimated.  The  ends  of  the  bacilli  are  square  though  sometimes,  according 
to  some  writers,  rounded  or  even  slightly  bulbous  and  occasionally  even 
slightly  concave.  In  the  blood  of  animals,  each  organism  and  chain  of  or- 
ganisms is  surrounded  by  a  distinct  capsule  readily  brought  out  by  certain 


ANTHRAX  159 

staining  methods.  Cultivated  upon  artificial  culture  media — with  the  ex- 
ception of  fluid  blood  serum — this  capsule  does  not  appear.  Degeneration 
or  involution  forms  of  the  bacilli  are  not  infrequently  met  with  in  preparations 
of  blood  or  tissue  pulp — especially  if  putrefactive  changes  have  occurred — 
as  well  as  in  culture  media.  In  these  forms  the  protoplasm  stains  irregularly 
or  not  at  all,  just  the  outer  shell  being  visible  and  this  may  be  more  or  less 
filled  with  dark  staining  granules.  Sometimes  also  capsules  are  observed  which 
are  either  empty  or  contain  remains  of  bacilli. 

The  bacillus  is  readily  stained  by  any  of  the  simple  stains  and  is  Gram 
positive.  The  spores  may  be  stained  by  the  usual  methods  recommended  to 
color  these  bodies. 

Cultural  Characteristics. — The  bacillus  is  a  strict  aerobe  though  Rosenthal 
by  depriving  it  more  and  more  of  oxygen  succeeded  in  converting  it  into  a 
facultative  anaerobe.  Development  occurs  on  artificial  media  at  any  tem- 
perature between  i2°C.  and  43°C.  but  the  optimum  is  about  35°C.  and  at 
this  temperature  an  extensive  growth  is  evident  in  12  hours.  Spores  are 
said  to  form  at  temperatures  between  18°  and  42°C. 

On  some  of  our  laboratory  media  the  growth  has  certain  characteristics 
which,  however,  are  not  diagnostic  (although  at  one  time  so  considered)  for  a 
number  of  bacteria  belonging  to  this  group  possess  very  similar  character- 
istics and  confusion  is  easy  even  if  such  organisms  are  cultivated  side  by 
side  with  anthrax.  Thus  the  "Medusa"  colony  on  the  gelatine  plate,  the 
inverted  fir-tree  in  the  gelatine  stab  (with  rapid  liquefaction  of  the  media  in 
both  instances);  a  somewhat  similar  colony  on  the  agar  plate  and  agar  slant; 
the  gradual  liquefaction  of  Loeffler's  blood  serum;  the  clear  bouillon  (without 
pellicle)  above  a  cotton-like  sediment  (best  seen  by  lightly  agitating)  which 
soon  becomes  more  like  sputum — such  characteristics  must  be  considered  of 
limited  diagnostic  value  only,  not  alone  on  account  of  the  group  character- 
istics referred  to,  but  also  because  of  deviation  from  type  due  to  slight  varia- 
tions in  different  lots  of  culture  media,  different  "strains"  of  anthrax,  and 
different  conditions  of  cultivation. 

Twelve-  to  24-hour  cultures  on  plain  agar  slants  made  for  diagnostic 
purposes  from  the  blood,  organs,  or  local  lesions  of  animal  or  man,  are 
frequently  contaminated  with  other  organisms  especially  if  made  from 
animals  several  hours  after  death.  If  such  cultures  show  colonies — and  some- 
times there  may  be  only  one — or  a  more  diffuse  growth  somewhat  resembling 
morphine  sulphate  crystals  or  damp  snow,  with  perhaps  flaring  edges,  and 
further  appear  (with  the  hand  lens  and  transmitted  light)  like  frosted  or 
even  corrugated  glass,  suspicion  is  at  once  aroused  and  proof  of  anthrax 
must  be  established  by  animal  inoculation  (guinea-pig,  or  better,  mouse). 

Tenacity. — The  vegetative  rods  are  readily  destroyed  by  heat  and  chemi- 
cals, the  spores  on  the  contrary  are  very  difficult  to  kill.  Thus  the  bacilli  may 
be  killed  by  a  dry  temperature  of  55°  to  58°C.  in  10  to  15  minutes,  while  dry 
heat  at  i4o°C.  for  3  hours  is  necessary  to  destroy  the  spores.     Moist  heat,  on 


I 


l6o  OCCUPATIONAL   INFECTIOUS    DISEASES 

the  Other  hand,  as  steam  at  95°C.,  will  kill  spores  in  lo  minutes  and  steam  at 
ioo°C.  in  I  to  3  minutes,  and  boiHng  water  will  kill  spores  in  5  minutes.  Low 
temperature,  even  —  ioo°C.  for  an  hour,  does  not  injure  either  bacillus  or 
spore,  and  at  —  i8o°C.  (liquid  air)  spores  and  bacilli  are  still  alive  after  3  to 
15  hours  (Ravanel,  Belli).  Bacilli  will  survive  —  i30°C.  for  a  "few  hours," 
—  24°C.  for  12  days,  and  —  io.6°C.  for  24  days. 

In  gastric  juice  the  bacilli  die  in  15  to  20  minutes  but  the  spores  are  not 
destroyed. 

In  fairly  thick  blood  or  spleen  smears  dried  on  glass  slides  and  kept  in  a 
room,  a  few  bacilli  of  the  many  thousands  present  may  still  be  alive  at  the 
end  of  18  to  20  days  (Frothingham),  and  Momont  says  that  in  dried  rabbit's 
blood  at  room  temperature,  they  will  remain  alive  for  57  days.  It  is  well 
known  to  all  bacteriologists  that  spores  dried  on  silk  thread  and  kept  in  the 
laboratory  without  special  precaution  against  diffuse  daylight,  retain  their 
vitality  and  virulence  for  many  years  (20  at  least)  and  perhaps  indefinitely. 

Sunlight  at  25°  to  3o°C.  kills  bacilli  in  dried  blood  in  63^^  to  15  hours 
according  to  the  thickness  of  the  layer,  while  spores  dried  on  silk  threads 
will  withstand  direct  sunlight  for  100  hours  (Momont).  According  to 
Neumark,  bacilli  and  spores  on  agar  plates  are  killed  in  20  to  30  minutes  by 
sunlight,  and  diffuse  daylight  destroys  bacilli  in  about  11  hours  and  spores 
in  2  days. 

These  and  the  following  widely  differing  results  of  various  experimenters 
are  partly  explained  by  the  dissimilarity  of  conditions  under  which  the  ob- 
servations were  made.  For  example,  it  has  been  shown  that  different 
"races"  or  "strains"  of  anthrax  bacilli  have  different  resisting  powers. 
Resistance  also  depends  upon:  the  age  of  the  spore  (24-hour  spores  are  said 
to  be  especially  resistant);  the  temperature  at  which  the  spore  was  produced; 
the  object  upon  which  it  was  dried  for  experimentation,  for  in  porous  sub- 
stances (silk,  filter  paper,  cotton)  organisms  are  less  easily  destroyed  than 
on  smooth  surfaces  (glass,  stone).  Spores  on  threads  are  said  by  one  ob- 
server to  be  more  resistant  than  spores  in  emulsion  and  another  writer  finds 
the  opposite.  It  is  said  that  i  to  1000  corrosive  sublimate  will  destroy  anthrax 
spores  in  20  minutes,  but  if  albumen  is  present  as  in  the  blood,  its  action  is 
untrustworthy,  Fraenkel  says  spores  are  destroyed  by  a  0.5  per  cent,  solu- 
tion of  corrosive  in  40  minutes  and  Geppert  that  they  are  not  entirely  de- 
stroyed by  this  solution  in  2  to  3  hours,  but  that  a  i  per  cent,  solution  will 
kill  them  in  6  to  12  minutes,  while  Heider  states  that  a  i  per  cent,  sublimate 
does  not  destroy  in  3  hours. 

In  5  per  cent,  carbolic  acid,  Koch  says  that  the  spores  are  dead  in  2  days; 
Guttmann  in  37  days,  and  Fraenkel  that  they  are  still  alive  after  40  days. 
Von  Esmark  found  the  spores  of  one  strain  were  killed  in  4  days,  in  another 
they  were  still  capable  of  cultivation  after  40  days'  exposure  to  5  per  cent, 
carbolic;  while  if  warmed  to  37°C.  they  were  destroyed  in  2  to  3  hours  and 
at  9°  to  io°C.  there  were  still  living  at  the  end  of  10  days. 


ANTHRAX  l6l 

Lysol  (5  per  cent.)  kills  the  spores  in  7  hours  (Foth);  creolin  (10  per 
cent.)  will  kill  bacilli  in  10  to  20  minutes  but  spores  are  not  harmed  even  by  a 
60  per  cent,  solution  (Sirena  and  Alessi);  chlorine  water  (Chlorwasser) 
(0.2  per  cent.)  destroys  spores  in  15  seconds  (Geppert);  antiformin  (5  to 
10  per  cent.)  completely  dissolves  bacilli  and  spores  in  a  short  time  (KoUe 
and  Wassermann);  formalin  (i  per  cent.)  kills  spores  after  2  hours,  2  to  5 
per  cent,  in  1  hour,  10  to  20  per  cent,  in  10  minutes  (Hammer  and  Feitler), 
undilulted  formalin  (40  per  cent,  formaldehyde)  in  i  to  5  minutes;  in  a 
dilution  of  i  to  20,000,  formalin  arrests  the  development  of  anthrax  bacilli 
in  bouillon  cultures  (Aronson). 

In  soil  the  bacilli  die  out  fairly  rapidly  but  the  spores  are  said  to  survive 
for  15  years  (Sirena,  by  Besson)  and  in  water  for  17  months.  On  the  in- 
side of  a  manure  pile  a  temperature  from  76.5°  to  72°C.  is  said  to  destroy 
spores  in  4  days  (Pheiler,  by  Hutyra  and  Marek). 

"Pickling  destroys  the  bacilli  in  meat  after  i}^  months  (Peuch),  but  it 
does  not  affect  the  spores  (Abel).  The  drying  and  salting  of  hides  does  not 
destroy  the  attached  spores  which  may  remain  virulent  for  125  days  on 
hides  that  have  been  treated  with  fresh  milk  of  lime  (Griglio).  In  sun- 
light, hides  containing  the  bacilli  are  sterilized  in  63^^  to  7  hours  while  those 
containing  spores  are  not  sterilized  even  after  exposure  for  13  hours  (Esmarch). 
Quick  lime  solution  and  lime  kill  the  spores  in  the  tanning  process  in  12  to 
17  days.  Infusion  of  quebracho  bark*  does  not  affect  them  in  12  days 
(Keszler) .  .  .  as  a  matter  of  fact  at  the  present  time  there  is  no  method 
known  for  an  effective  disinfection  of  hides  without  injuring  them  for  their 
technical  utilization  (Xylander) Horsehair  is  effectively  disin- 
fected by  dry  heat  at  iio°C.  followed  by  steam  at  iooC°.  (de  Rossi).  The 
officially  required  disinfection  of  railroad  stock  cars  in  Germany  with  5  per 
cent.  "Kresulfol"  (cresol-sulfonic  acid)  was  found  by  Schniirer  to  be  abso- 
lutely ineffective  against  anthrax  spores  and  he  recommended  instead  the 
disinfection  with  0.5  per  cent,  formaldehyde  solution"  (Hutyra  and  Marek). 

Anthrax  in  Animals. — The  disease  in  animals  is  world  wide  in  its  dis- 
tribution and  has  been  known  for  centuries.  The  animals  most  susceptible 
to  the  natural  disease  are  cattle,  sheep,  horses,  hogs,  and  carnivora,  in  the 
order  named,  though  infection  in  the  last  is  exceptional,  resulting  as  a  rule 
from  the  ingestion  of  flesh  of  anthrax  animals.  Algerian  sheep,  domestic 
fowls  (probably  most  birds)  and  the  cold-blooded  animals  are  not  sus- 
ceptible to  the  natural  disease  and  are  exceedingly  resistant  to  artificial 
infection.  Of  the  laboratory  animals,  mice  (white  and  gray),  guinea-pigs, 
and  rabbits  are  readily  infected  even  with  minute  doses.  Rats  are  less 
susceptible,  especially  black  rats. 

Cattle  in  spite  of  their  susceptibility  to  spontaneous  anthrax,  are  fre- 
quently quite  resistant  to  inoculation  even  surviving  relatively  large  doses  of 
virulent  organisms.     Sheep  on  the  contrary  seem  to  be  as  susceptible  to 

*  Used  for  tanning  purposes. 


l62  OCCUPATIONAL   INFECTIOUS   DISEASES 

inoculation  as  to  natural  infection.  Hogs,  although  they  may  have  the 
septicemic  form,  are  much  less  susceptible  and  possess  a  relatively  high 
natural  resistance  to  inoculation  (subcutaneous,  intraperitoneal,  spore 
feeding).  In  the  majority  of  instances,  the  infection  remains  localized  in 
the  pharyngeal  region. 

Natural  Infection  in  Animals. — In  the  herbivorous  animals  this  usually 
takes  place  through  food  or  water  containing  anthrax  spores,  and  it  is  stated 
that  large  numbers  of  spores  are  usually  necessary  to  produce  infection  in  this 
manner.  The  food  becomes  contaminated  by  being  grown  on  anthrax 
infected  soil.  The  soil  becomes  infected  in  a  variety  of  ways  and  perhaps 
the  commonest  way  is  from  anthrax  carcasses.  If  an  animal  dies  at  pasture 
or  is  dragged  over  the  ground  for  burial,  blood,  urine,  and  feces,  containing 
bacilli,  escape  from  the  natural  openings  and  are  scattered  over  the  soil; 
but  a  more  proHfic  source  is  the  unburied  or  superficially  buried  carcass. 
Bacilli  from  an  unburied  carcass  are  soon  distributed  about  by  wild  animals, 
dogs,  birds,  and  insects  and  even  fairly  deep  burial  does  not  preclude  upper 
soil  contamination  for  bacilli  and  spores  may  be  brought  to  the  surface  by 
rising  ground  water  and  perhaps  by  worms.  The  bacilli  not  being  very 
resistant  may  be  destroyed  by  sunhght  or  other  adverse  conditions,  but  under 
favorable  circumstances,  they  develop  into  the  exceedingly  resistant  spores 
which  may  remain  virulent  for  years.  Moreover  under  proper  conditions, 
these  spores  may  germinate  resulting  in  innumerable  bacilli  which  in  turn 
sporulate.  Spores  may  even  reach  the  soil  directly,  for  the  intestinal  con- 
tents often  contains  spores  as  well  as  bacilli;  also  from  opened  carcasses  on 
the  way  to  interment,  for  in  the  opened  carcasses  spores  are  frequently 
formed  shortly  after  exposure  to  the  air.  Winds  may  carry  dry  spores  to 
neighboring  localities  and  rains  wash  them  into  brooks  and  streams.  Thus 
arise  "anthrax  pastures"  and  "anthrax  fields,"  and  animals  grazing  over 
them  may  become  infected;  also  crops  grown  on  them  may  become  contam- 
inated with  spores  and  if  sent  to  other  locaHties  may  be  the  cause  of  new 
centers  of  infection. 

Anthrax  infection  in  animals  is  recorded  from  fields  contaminated  with 
dust  blown  from  a  Persian  wool  factory  and  a  horsehair  factory  (Oliver); 
Soil,  food,  and  water  also  become  contaminated  by  the  "drainage  water  and 
waste  from  tanneries,  wool-works  and  horsehair  mills"  (Hutyra  and  Marek). 
by  fertilizers  made  from  animal  tissues;  by  the  feet,  bill  and  vomitus  of 
buzzards;  and  the  feet  of  flies  and  ants  which  have  fed  on  anthrax  carcasses. 
The  material  regurgitated  by  such  flies  and  their  feces  (also  the  feces  of  the 
house-fly  fed  with  spores)  contain  anthrax  organisms;  the  feces  of  buzzards 
do  not  (Dalrymple,  Mitzmain,  Darhng  and  Bates,  Graham-Smith).  Dal- 
rymple  made  feeding  experiments  with  the  turkey  buzzard  (Cathartes  auro), 
the  carrion  crow  (Catharista  atrata),  the  dog,  pig,  cat,  oppossum  (Didelphys 
virginiana)  and  the  common  fowl.  He  found  no  anthrax  infection  in  the 
feces  of  buzzards  and  crows,  but  little  in  the  stomach  (24  hours  after  feeding 


ANTHRAX  I 6^ 

spores)  and  none  further  on  in  the  intestine.  On  the  beak  and  feet  virulent 
anthrax  bacilU  were  found  for  48  hours  after  feeding  anthrax  rabbits,  and 
in  the  vouiitus  of  buzzards  2  hours  after  such  feeding.  Dogs  fed  with  spores 
showed  virulent  anthrax  in  their  feces  for  6  days;  pigs  for  5  days;  cats  and  the 
oppossum  3  days  and  the  common  fowl  48  hours. 

Food  in  stables  may  become  infected  by  drying  anthrax  hides  in  hay  lofts 
and  other  places  where  the  blood  from  the  hides  may  drop  onto  hay  or  other 
food;  also  the  blood  or  discharges  of  anthrax  animals  may  contaminate  food. 
Bone  meal  made  from  anthrax  carcasses  and  prepared  foods  may  also  con- 
tain infection.  Stockman  notes  a  great  decrease  in  anthrax  in  England 
from  April  to  September  when  animals  are  apt  to  be  at  pasture  and  a  sudden 
increase  after  the  time  when  they  are  returning  to  artificial  food.  He  there- 
fore attributes  outbreaks  less  to  pastures  than  to  food  stuffs  (cake)  and  has 
known  them  to  follow  distribution  of  Soya  beans.  In  one  instance,  Dr. 
Peters  and  I  thought  infection  resulted  from  refuse  from  a  carpet  factory 
used  for  bedding. 

Infection  may  also  occur  from  the  bites  of  flies  which  have  previously 
sucked  the  blood  from  an  anthrax  animal,  thus  giving  rise  to  the  carbuncular 
form  (Dalrymple).  Mitzmain  showed  experimentally  that  anthrax  could 
be  transmitted  by  Stomoxys  calci trans  and  Tabanus  striatus,  though  not 
with  regularity.  He  found  that  the  feces  of  these  flies  contained  virulent 
anthrax  bacilli  for  9  days  after  sucking  the  blood  from  an  anthrax  animal. 
Cultures  obtained  later  than  9  days  after  feeding  were  avirulent,  though 
"all  of  the  oridnary  cultural  and  morphological  tests  were  positive  from  the 
ninth  to  the  twentieth  day  with  material  obtained  from  Stomoxys  calcitrans 
and  from  the  sixth  to  the  tenth  with  material  obtained  from  Tabanus  stria- 
tus." The  experiments  were  carried  on  for  20  days.  Spores  were  not 
demonstrated  either  in  the  body  of  the  flies  or  fresh  feces.  The  possi- 
bility of  spores  developing  in  older  fecal  deposits  was  not  included  in  these 
experiments. 

Symptoms  in  Animals. — The  incubation  period  after  ingestion  of  spores 
is  from  3  to  10  days.  The  spores  are  not  destroyed  by  the  gastric  juice  and 
pass  into  the  intestine  where  they  develop  into  bacilli,  multiply  and  invade 
the  blood  by  way  of  the  lymph  channels.  Thus  the  disease  becomes  a  true 
septicemia  and  the  animals  may  die  in  a  short  time  without  showing  very 
characteristic  symptoms. 

The  peracute  form  simulates  cerebral  apoplexy  and  is  seen  most  frequently 
in  sheep.  The  animal  suddenly  falls  in  convulsions,  blood  oozes  from  the 
nose,  mouth,  and  anus,  and  death  occurs  perhaps  within  an  hour. 

The  acute  and  subacute  forms  are  much  more  common.  Symptoms  are 
frequently  not  observed;  the  animal  appearing  well  in  the  evening  is  found 
d3dng  or  dead  in  the  morning,  or  the  disease  may  last  for  2  or  3  days,  and  in 
exceptional  cases  even  longer.  If  symptoms  are  noted,  they  are  usually 
those  of  an  acute  infectious  disease  not  especially  indicating  its  specific 


164  OCCUPATIONAL   INFECTIOUS    DISEASES 

character.  In  some  cases,  more  especially  in  the  horse,  rapidly  growing 
oedematous  swelhngs,  hot,  doughy  or  dense,  may  appear  in  any  region  of  the 
body  but  are  more  apt  to  be  on  the  neck,  breast,  flank,  or  lumbar  region. 
When  on  the  neck  there  is  usually  a  more  or  less  severe  oedema  of  the  glottis. 
In  horses,  also,  there  is  usually  a  severe  spasmodic  coL'c. 

Milk  secretion  is  suspended  early  in  the  disease  or,  if  secreted  in  small 
quantities,  is  apt  to  be  bloody.  MacFadyean  found  many  anthrax  bacilli  in 
the  milk,  drawn  after  death,  of  three  cows.  Moore  found  bacilli  in  the 
milk  of  a  cow  at  the  time  of  death,  but  was  unable  to  do  so  "in  the  milk  of 
cows  in  advanced  stages  of  the  disease." 

Carhuncular  anthrax  is  not  so  frequently  seen  in  animals  as  in  man,  though 
Dalrymple  reports  outbreaks  of  this  form  in  the  lower  Mississippi  Valley  dur- 
ing the  period  when  the  horse  fly  (Tabanus  striatus)  is  most  abundant.  In 
his  experience,  while  initial  cases  of  intestinal  anthrax  frequently  occur  in  the 
late  spring  or  early  summer,  the  disease  is  more  prevalent  later  as  the  car- 
huncular form  and  is  widely  spread  by  the  bites  of  various  species  of  the  horse 
fly  (Tabanids)  which  have  previously  sucked  the  blood  of  infected  animals, 
and  the  more  plentiful  the  flies  the  more  prevalent  the  disease. 

Anatomical  Changes. — The  most  conspicuous  pathological  conditions  are 
a  fluid,  tarry  blood,  and  a  very  much  enlarged  spleen,  its  pulp  being  dark  and 
tar-like  and  usually  very  soft,  even  fluid.  There  may  also  be  more  or  less 
extensive  hemorrhages  and  oedematous  gelatinous  infiltrations  in  the  subcu- 
taneous and  intermuscular  connective  tissue,  the  mesentery,  pleura,  pharynx, 
and  epiglottis.  The  small  intestine — -rarely  the  stomach  or  large  intestine — 
may  be  swollen  and  congested  with  sometimes  areas  of  necrosis.  The  lymph 
glands  are  usually  much  swollen,  moist  and  hemorrhagic,  especially  the  mesen- 
teric and  those  near  gelatinous  infiltrations. 

In  the  horse  and  pig  the  chief  lesions  are  frequently  confined  to  the  lymph 
glands  and  to  gelatinous,  hemorrhagic  swellings  around  the  throat.  The 
enlarged  spleen  may  be  absent,  especially  in  swine.  The  blood  often  contains 
no  anthrax  bacilli  after  death,  but  they  are  found  in  the  lymph  glands  and 
oedematous  fluid.  In  the  pig  there  may  also  be  necrotic  areas — the  size  of  a 
quarter — on  the  mucous  membrane  of  the  pharynx,  with  almost  black  centers; 
these  are  of  much  diagnostic  value  and  there  is  no  difficulty  in  finding  bacilli 
in  such  foci. 

Much  has  been  written  recently  in  Germany  regarding  local  anthrax  in 
hogs,  especially  lymph-gland  anthrax,  which  does  not  terminate  fatally. 
Animals,  apparently  perfectly  healthy,  are  found  in  the  slaughterhouses  show- 
ing nothing  but  a  few  somewhat  enlarged,  yellow  to  deep  red  lymphatic  glands. 
This  condition  may  be  confined  to  a  single  node  of  a  group  or  even  to  a  re- 
latively small  portion  of  the  node,  but  from  these  lesions — frequently  with 
difficulty — anthrax  bacilli  have  been  recovered,  although  they  could  not  be 
found  in  other  organs  or  the  blood,  and  moreover  the  Ascoli  reaction  failed 


ANTHRAX  165 

except  with  material  from  these  infected  glands.  Such  infection  is  supposed 
to  be  caused  by  certain  foods,  especially  fish-meal  (Fischmehl). 

Diagnosis.— The  capsule  which  surrounds  the  bacilli  in  the  blood  is  of 
great  diagnostic  importance,  for  it  is  believed  that  this  is  the  only  large 
bacillus  found  in  the  blood  and  organs  -of  dead  animals  that  has  this  pecul- 
iarity. The  numerous  large  putrefactive  or  cadaver  bacilli  appearing  in  the 
blood  and  tissues  of  animals  (cattle,  horses,  sheep  and  swine)  shortly  after 
death,  and  even  while  moribund,  have  frequently  been  mistaken  for  anthrax. 
These  organisms,  however,  do  not  possess  a  capsule.*  It  is  therefore  ex- 
tremely important  to  stain  such  suspected  material  by  a  method  which  will 
bring  out  this  capsule  if  present,  for  if  special  methods  are  not  employed  the 
capsules  will  not  be  seen.  Numerous  methods  have  been  recommended,  of 
which  the  first  two  following  have  proved  very  useful  in  my  experience. 

Smears  of  blood  or  tissue  pulp,  made  fairly  thick,  should  be  air  dried  and 
fixed  by  passing  rapidly  three  times  through  the  flame,  care  being  taken  not 
to  overheat  or  the  capsules  will  be  injured. 

Johne's  Method. — -i.  Stain  the  smear  for  about  30  seconds,  heating 
gently,  with  2  per  cent.  Gentian  violet  (dye  2  parts,  water  85  parts,  boil  for 
5  to  10  minutes  and  after  cooling  add  15  parts  of  90  per  cent,  alcohol,  mix  and 
filter  twice).  2.  Wash  in  water.  3.  Decolorize  in  i  to  2  per  cent,  acetic  acid 
5  to  20  seconds  according  to  the  thickness  of  the  smear.  4.  Wash  in  water. 
5.  Mount  and  examine  in  water;  if  not  sufficiently  decolorized,  remove  cover 
slip  with  knife  blade  and  repeat  No.  3.  The  capsules  are  colorless  and  the 
bacilli  violet. 

The  method  I  most  frequently  employ  is  simply  a  modification  of  the 
above;  that  is,  decolorize  with  95  per  cent,  alcohol  instead  of  i  to  2  per  cent, 
acetic  acid.  Sometimes  it  is  helpful  to  substitute  for  Gentian  violet  Loef- 
fler's  alkaline  methylene  blue,  for  with  this  stain  the  capsules,  although  they 
may  be  colorless  by  daylight,  often  show  a  delicate  pink  color  if  examined  by 
artificial  light.  Fairly  thick  smears  of  heart's  blood  and  liver  pulp  of  an 
anthrax  mouse  made  on  a  slide  and  kept  for  5  years  on  the  laboratory  shelf 
(behind  glass  doors)  still  showed  excellent  capsules  on  most  of  the  bacilli 
(Frothingham). 

In  view  of  these  facts  regarding  the  capsule  and  also  the  fact,  above 

referred  to,  that  cultures  may  be  obtained  from  such  dried  material  for  about 

20  days,  I  have  found  it  convenient  and  practical  for  diagnostic  purposes  to 

recommend  that  several  smears  of  blood  or  other  material  from  suspected 

animals  or  man  should  be  air  dried  (not  with  artificial  heat  or  sunlight)  on 

clean  glass  and  forwarded  to  the  laboratory.     As  it  is  unwise  to  open  an 

anthrax-suspected  animal,  it  is  best  to  take  blood  from  a  superficial  vein. 

The  smear  of  blood  should  not  be  so  thick  that  it  cracks  away  upon  drying, 

*  According  to  Noetzl,  Berndts,  Bongert,  and  others,  some  of  these  bacilli  may  oc- 
casionally show  a  capsule,  though  this  is  probably  less  pronounced  than  the  anthrax  capsule. 
It  must  also  not  be  forgotten  that  in  true  anthrax  the  capsule  cannot  always  be  demon- 
strated, especially  in  horses  and  carnivora. 


1 66  OCCUPATIONAL  INFECTIOUS   DISEASES 

but  it  must  be  dried,  for  if  at  all  moist,  other  organisms  which  may  be  present 
will  multiply  rapidly  and  obscure  cultures  and  microscopic  preparations. 
At  the  laboratory,  a  portion  of  the  blood  is  softened  with  sterile  water  and 
smeared  in  various  quantities  over  several  slant  agars,  the  object  being  to  ob- 
tain isolated  colonies.  Any  suspicious  colonies  or  growth  appearing  after  12 
to  24  hours'  incubation  (see  page  159)  may  be  further  tested  in  mice  and  sub- 
cultures. Another  portion  of  the  softened  blood  is  smeared  on  cover  glasses 
and  stained  for  capsules,  or  one  of  the  original  smears  is  stained. 

MacFaydean  recommends  staining  air-dried  and  gently  fixed  smears  with 
a  I  per  cent,  aqueous  solution  of  methylene  blue  for  a  few  seconds  and  de- 
scribes a  peculiar  color  reaction  of  the  amorphous  material  in  the  smear,  not 
necessarily  in  the  immediate  vicinity  of  the  bacilli  but  probably  derived  from 
their  capsules.  This  in  smaller  or  larger  granules  or  masses  takes  on  a 
"violet"  or  "reddish  purple"  color  which  is  in  sharp  contrast  to  the  blue 
bacilli  and  nuclei  and  is  especially  well  seen  by  artificial  light.  He  considers 
the  reaction  of  much  diagnostic  value  as  it  occurs  in  smears  of  blood,  oedema, 
and  organ  pulp  of  anthrax  animals  and  not  in  similar  preparations  from 
animals  dead  of  other  diseases. 

Frequently  pure  cultures  of  anthrax  may  be  obtained  from  much  con- 
taminated material  by  heating  a  24-hour  mixed  culture  to  8o°C.  for  3^  hour 
and  plating  or  streaking  out  on  agar. 

Another  good  practice  is  to  forward  the  ear  of  the  suspected  animal  to 
the  laboratory  where  blood  may  be  pressed  from  the  vessels  for  microscopic 
examination  and  cultures. 

Ascoli  Reaction. — Ascoli  has  worked  out  a  precipitine  reaction  which  has 
met  with  much  approval  and  seems  especially  useful  since  it  can  be  employed 
with  small  portions  of  organs  and  in  cases  where  putrefaction  is  so  advanced 
that  bacteriological  verification  is  impossible.  It  is  said  that  this  reaction 
is  not  effected  by  preserving  anthrax  tissues  in  glycerine,  alcohol,  or  even 
formalin,  and  that  the  method  may  be  used  to  detect  anthrax  hides  and  food 
stuffs  (sausage  meat,  etc.). 

The  complement  fixation  method  has  been  recommended,  but  does  not 
seem  to  be  as  useful  as  the  Ascoli  test. 

Prevention. — Grazing  should  not  be  permitted  on  lands  known  or  sus- 
pected to  be  sources  of  infection,  though  it  is  frequently  possible  to  fence  off 
certain  stagnant  pools  or  other  suspicious  zones.  Usually  the  regions  which 
harbor  anthrax  infection  are  swampy  or  peaty,  subject  to  overflows,  the  soil 
loose  and  warm  and  resting  perhaps  on  impervious  substrata,  also  naturally 
wet  regions  (fens,  deltas,  bottom  lands)  which,  however,  make  available 
pastures  in  dry  seasons.  The  only  rational  treatment  of  such  lands  is 
thorough  drainage  and  proper  cultivation,  and  they  should  not  be  used  again 
for  grazing  purposes  for  several  years.  In  this  cpnnection  it  is  important  to 
remember  that  part  of  the  life  history  of  various  tabanids  is  semi-aquatic, 


ANTHRAX  167 

and  drainage  therefore  greatly  reduces  the  number  of  these  insects  and  hence 
tends  to  eliminate  one  source  of  the  spread  of  anthrax. 

If  an  animal  dies  at  pasture  great  care  must  be  taken  to  avoid  contamina- 
tion of  the  ground  with  its  blood  or  discharges,  and  other  animals  should  be 
immediately  removed.  The  carcass  should  not  be  skinned  or  opened;  if 
possible  it  should  be  burned,  otherwise  covered  with  powdered  unslaked 
Hme  and  buried  at  least  6  ft.  deep  in  an  unfrequented,  fenced-oflf  place,  and 
ground  known  or  suspected  to  have  been  contaminated  with  discharges 
should  be  burned  over.  If  a  carcass  has  been  attacked  by  dogs,  wild  animals, 
buzzards,  crows,  etc.,  the  danger  of  spreading  infection  is  much  increased; 
such  creatures  should  be  killed  when  possible  and  considerable  ground  in 
the  vicinity  of  the  carcasss  burned  over. 

Suspicious  food  supply  must  be  discontinued  and  destroyed.  If  an 
animal  dies  in  the  stable,  everything  suspected  of  being  contaminated  with 
its  discharges  should  be  thoroughly  disinfected,  burned  if  possible. 

Preventive  Inoculation  {Pasteur). — This  is  very  successful,  is  widely  used 
and  consists  in  the  inoculation  of  two  attenuated  cultures.  The  first  (Vaccine 
I)  is  very  much  attenuated  and  is  only  virulent  for  white  mice,  not  imiformly 
for  guinea-pigs.  Vaccine  II,  given  12  to  14  days  later,  is  virulent  for  guinea- 
pigs  but  not  v/ith  regularity  for  rabbits.  Active  immunity  is  established 
12  to  15  days  after  the  second  inoculation  and  lasts  for  10  to  12  months. 
It  may  be  transmitted  to  the  fetus  but  is  of  relatively  low  grade  and  of  short 
duration.  The  mortahty  from  anthrax  in  cattle  is  about  0.5  per  cent,  of 
the  treated  animals  (somewhat  higher  in  sheep),  and  the  death  rate  from 
anthrax  on  infected  farms  is  reduced  to  i  per  cent,  or  less  (Stockman). 

In  regions  where  infection  is  known  to  exist  protective  inoculation  should 
be  carried  out  early  each  spring  so  that  immunity  is  established  before  the 
animals  are  turned  out  (Dalrymple). 

An  anti-anthrax  serum  (Sclavo)  is  obtained  from  artificially  immunized 
animals  which  gives  passive  immunity  for  about  10  days  (rarely  2  to  3  months), 
long  enough,  however,  to  protect  against  exceptional  risks  of  infection.  For 
example,  if  an  animal  dies  among  others  and  its  blood  or  other  infectious 
material  spUt,  the  exposed  animals  may  be  given  the  serum  which  should 
protect  them  while  disinfection  is  being  carried  out  or  an  active  immunity 
is  being  estabhshed.  It  is  also  said  that  as  a  cure  in  animals  Sclavo's  serum 
has  frequently  been  used  with  success  even  after  the  baciUi  have  appeared 
in  the  blood. 

Simultaneous  preventive  vaccination  has  been  successfully  employed  since 
1902  in  "hundreds  of  thousands"  of  animals  (cattle,  sheep,  horses,  swine) 
in  many  countries — Argentina,  Uruguay,  Germany,  Austria-Hungary, 
Roumania,  etc.  It  is  a  combination  of  active  and  passive  immunization 
produced  by  the  simultaneous  injection  of  serum  and  an  attenuated  culture 
of  about  the  virulence  of  the  Pasteur  Vaccine  11.  The  advantages  over  the 
Pasteur  method  are:  only  one  treatment  required;  a  more  rapidly  acquired 


l68  OCCUPATIONAL   INFECTIOUS   DISEASES 

immunity  (lo  to  12  days  after  inoculation)  which  is  of  a  high  grade  and  lasts 
for  I  year  and  perhaps  longer. 

General  preventive  measures^  are  of  much  importance.  Animals  from  in- 
fected districts  should  be  quarantined  and  the  importation  of  hides  carefully 
controlled  and  prohibited  from  infected  regions.  Imported  hides,  calf  skins, 
hide  cuttings  and  parings,  horns,  hoofs,  hair,  wool,  bristles,  glue  stock,  etc., 
should  be  disinfected  if  possible  and  certainly  the  waste  from  factories  hand- 
ling such  products  sterilized  before  it  is  permitted  to  reach  fields.  As  before 
pointed  out,  there  is  at  present  no  known  method  of  sterilizing  hides  without 
injuring  them,  but  the  Bureau  of  Animal  Industry  in  Washington  is  working 
on  this  problem  and  it  is  hoped  that  a  method  will  soon  be  devised.* 

Anthrax  in  Man. — The  intestinal  form  of  anthrax  is  rare  in  man  and  is 
caused  by  the  ingestion  of  infected  foods,  such  as  sausages  which  have  been 
made  from  the  meat  of  an  anthrax  animal,  or  the  flesh  of  such  an  animal  in- 
sufficiently cooked;  it  may  also  arise  from  eating  with  hands  not  properly 
cleansed  after  handling  infectious  material.  Pulmonary  anthrax  is  more 
common  and. arises  from  the  inspiration  of  dust  from  infected  wool,  rags, 
hair,  etc.,  which  contains  anthrax  spores^hence  the  names  "wool-sorter's 
and  rag-picker's  disease."  The  mortality  from  pulmonary  anthrax  is  about 
50  per  cent.,  and  less  than  this  in  the  intestinal  form.  The  more  usual  form 
in  man  is  the  carbuncular,  the  so-called  malignant  pustule,  and  is  the  result 
of  skin  infection,  bacilli  or  spores  gaining  access  through  cuts  or  abrasions 
of  any  kind,  and  probably  in  some  instances  directly  introduced  by  insect 
bites.  The  pure  septicemic  form  is  rare.  It  is,  therefore,  evident  that 
certain  occupations  favor  infection  and  the  disease  is  usually  met  with 
among  workers  on  hides,  hair,  bristles,  wool,  etc.,  and  in  laboratory  workers^ 
veterinarians,  meat  inspectors,  herders,  farmers,  cattle  men,  and  butchers. 

Oliver  reports  that  in  certain  woolen  districts  in  England  where  much 
foreign  wool  was  handled  anthrax  was  quite  common,  while  in  other  parts  of 
England  and  Scotland  where  only  colonial  or  home-grown  wool  was  manipu- 
lated the  disease  was  "  conspicuously  absent."  Legge  reports  that  there 
were  261  cases  of  anthrax  in  the  factories  and  work  shops  of  England  in  6 
years  (1899-1904);  of  these,  88  occurred  in  worsted  and  wool  factories,  70 
in  horsehair  and  bristle  works,  86  among  workers  on  hides  and  skins,  and 
17  in  other  industries  67  cases  were  fatal.  "The  disease  has  appeared  mostly 
in  wool-sorting,  wool-combing  and  spinning  industries,  in  the  manipulation 
of  horsehair  for  stuffing  chairs  and  mattresses  and  in  the  preparation  of 

*  Since  this  was  written  the  U.  S.  Department  of  Agriculture  has  published  the  results 
of  experiments  by  F.  W.  Tilley:  "A  Bacteriological  Study  of  Methods  for  the  Disinfection 
of  Hides  Infected  with  Anthrax  Spores"  (Journal  of  Agricultural  Research,  Vol.  IV,  No. 
I,  April,  1915).  The  conclusions  are  that  although  "the  Schattenfroh  method  cannot  be 
regarded  as  perfect,  it  nevertheless  seems  to  be  far  superior  to  other  methods  and  well 
worth  a  trial  as  a  standard  method  for  the  disinfection  of  hides." 

The  Schattenfroh  method  consists  of  a  48-hour  exposure  of  the  hides  to  2  per  cent. 
hydrochloric  acid  and  10  per  cent,  sodium  chloride.  Experiments  are  still  going  on  to 
ascertain  the  effect  of  this  disinfection  upon  hides  as  regards  tanning,  but  it  seems  at 
present  that  the  method  has  no  injurious  effect  upon  hides  or  leather. 


ANTHRAX  169 

bristles  for  brush- making "  (Oliver).  Only  a  very  small  percentage  of  the 
persons  employed  became  infected. 

Hope  and  Hanna  report  60  cases  of  anthrax  in  Liverpool  which  occurred 
during  the  8  years  previous  to  191 2.  Of  these,  36  individuals  unloaded  or 
carted  hides  at  wharves,  13  handled  wool  and  6  horsehair.  In  1910  there 
were  only  9  cases  reported  in  England  and  but  11  in  191 1  (Thompson). 

In  the  United  States  the  disease  is  reportable  in  only  about  half  of  the 
states  and  general  statistics  are  lacking.  There  is  no  doubt,  however,  that 
a  certain  number  of  cases  occur  every  year.  Thus  in  Massachusetts  for  a 
number  of  years  there  has  been  an  average  of  two  deaths  annually.  In 
the  registration  area  of  the  United  States  there  were  18  deaths  in  191 2,  and 
an  annual  average  of  21  deaths  from  1906  to  19 10.  Ravenel  reported  12 
cases  in  Pennsylvania  in  1892  among  tanners  of  hides  from  China;  Thomp- 
son, three  cases  in  the  woolen  carpet  industry,  and  three  cases  were  re- 
ported in  New  York  state  in  the  year  1911-1912. 

A  record  of  the  reported  fatal  cases  of  anthrax  is  kept  by  the  United 
States  Bureau  of  the  Census.  In  the  4  years  1910  to  1914,  79 
such  fatal  cases  were  reported.  As  in  other  countries,  Andrews  points 
out  that  most  of  these  cases  occurred  among  persons  whose  occupations 
brought  them  in  contact  with  infected  material.  The  cases  included  farmers, 
tanners,  leather  workers,  brush  makers,  workers  on  hair  and  haircloth,  and 
assorters  of  hides.  The  most  frequent  source  of  infection,  Andrews  reports, 
was  among  assorters  of  hides.  Other  sources  of  infection  assigned  were: 
fine  wool  or  other  animal  hair,  diseased  cows,  rags,  old  clothes,  infected  knives, 
and  mosquito  bite. 

In  Germany,  where  records  are  more  carefully  kept,  there  were  in  the 
period  1900-1908,  1042  cases  of  anthrax  in  man  and  49,458  in  animals. 
In  1 910  there  were  287  cases  of  which  40  were  fatal;  in  1911,  281  cases  with 
40  deaths,  and  in  1912,  274  cases  with  36  deaths.  In  England,  in  1910,  51 
cases  and  9  deaths  were  reported;  in  191 1,  64  cases  and  11  deaths,  and  in 
191 2,  47  cases  and  6  deaths.  In  France,  in  1910,  191 1  and  191 2,  there  were 
54,  42  and  38  cases  respectively  reported.  John  B.  Andrews  states  that  not 
all  these  cases  were  due  to  the  worker's  occupation.  He  reports  that  in 
Germany  out  of  287  cases  that  occurred  in  1910,  24  were  among  persons  whose 
occupations  were  not  considered  a  factor  in  the  disease,  and  points  out  that 
many  cases  occurred  among  persons  of  agricultural  occupations.  In  Italy, 
1 890-1 900,  there  was  an  annual  average  of  about  2100  cases  among  people, 
and  in  Russia,  1 904-1 909,  an  average  of  16,000  per  year  (Kolle  and 
Wassermann). 

Anthrax  in  man  is  observed  in  the  following  forms:  External  Anthrax: 
(a)  Malignant  Pustule,  (b)  Malignant  Anthrax  (Edema.  2.  Internal 
Anthrax:  (a)  Intestinal,  (b)  Pulmonary  (Wool-sorter's  Disease). 

Sjonptoms.  i.  External  Anthrax,  (a)  Malignant  Pustule. — The  incu- 
bation period  is  from  i  to  3  days  and  the  point  of  infection  is  usually  the 


170  OCCUPATIONAL  INFECTIOUS   DISEASES 

hand,  arm,  face,  neck,  etc.,  i.e.,  exposed  parts  likely  to  come  into  contact 
with  hides  and  parts  frequently  scratched  with  the  finger  nails.  Often 
within  a  few  hours  after  infection  there  is  itching  and  uneasiness  and  the 
gradual  formation  of  a  small  hard  pustule  which  soon  becomes  vesicular  and 
discharges  a  bloody  serum,  and  within  36  hours  there  is  a  dark  brownish 
eschar.  Inflammatory  induration  extends  around  the  point  of  infection  and 
at  a  little  distance  there  may  fee  a  series  of  small  vesicles.  (Edema  causes 
marked  swelling  of  the  parts,  the  inflammation  extends  along  the  lymphatics 
and  the  neighboring  glands  are  swollen  and  sensitive.  The  temperature 
rises  rapidly  at  first,  later  falling  and  frequently  becoming  subnormal. 
There  is  much  variation  in  the  severity  of  the  cases;  death  may  take  place  in 
3  to  5  days;  where  recovery  occurs  the  constitutional  symptoms  are  less 
marked,  the  eschar  gradually  sloughs  and  the  wound  heals.  In  the  mildest 
form  there  may  be  but  httle  swelling,  the  inoculation  papule  rapidly  vesicu- 
lates and  the  resulting  scab  separates  in  a  few  days  (Osier). 

(b)  Malignant  anthrax  oedema  is  observed  in  the  loose  connective  tissue 
of  the  eyehd,  hand,  neck,  thigh,  etc.,  and  is  characterized  by  absence  of 
redness,  papules  and  vesicles,  but  by  the  presence  of  extensive  oedema — 
following  rather  than  preceding  constitutional  symptoms — which  is  not 
well  circumscribed,  spreads  rapidly  and  is  apt  to  terminate  in  sloughing  and 
gangrene.  The  mortality  in  infections  about  the  head  is  26  per  cent. 
(Narsarow)  and  infections  of  the  legs  5  per  cent.  (Osier,  Thompson). 

2.  Internal  Anthrax,  (a)  Intestinal. — This  form  results  from  the  in- 
gestion of  anthrax-infected  foods  (see  page  168),  though  it  may  follow  the 
external  type  if  the  bacilli  are  carried  to  the  mouth  from  the  external 
lesions.  The  symptoms  are  those  of  intense  poisoning:  chill,  followed  by 
fever,  vomiting,  diarrhea  or  constipation,  pain  in  various  parts  of  the  body, 
dyspnoea,  and  cyanosis.  There  may  be  hemorrhages  from  the  mucous  mem- 
branes; the  spleen  is  enlarged  and  the  blood  is  dark  and  does  not  coagulate 
after  death.  Butler  and  Huber  mention  an  instance  where  25  people  be- 
came infected  after  eating  meat  from  an  anthrax  animal  and  six  died  in 
from  48  hours  to  7  days  (Osier). 

(b)  Pulmonary  Anthrax,  Wool-sorter's  Disease. — This  results  from  in- 
haling dust  containing  anthrax  spores.  The  symptoms  correspond  more 
or  less  to  those  of  the  intestinal  type  with  the  addition  of  rapid  respiration, 
cough  and  pain  in  the  chest.  Death  may  occur  in  24  hours;  when  the  dis- 
ease is  of  longer  duration  there  may  be  dehrium  and  unconsciousness  (Osier). 
Oliver  notes  that  although  this  form  of  anthrax  is  usually  fatal  in  2  to  4 
days,  there  is  an  absence  of  the  severe  symptoms  usually  accompanying  acute 
infections,  and  "  the  characteristic  feature  is  the  rapidity  with  which  collapse 
sets  in." 

Diagnosis. — The  symptoms  and  history  are  sufficient  to  lead  to  a  suspicion 
of  anthrax  infection  and  laboratory  methods  must  be  resorted  to  for  diagnosis 
(page  165).     Anthrax  bacilli  may  be  demonstrated  in  the  fluid  from  the 


ANTHRAX  171 

pustules,  the  oedema,  sputum  (in  the  pulmonary  form),  and,  during  the  last 
stages  of  the  disease,  in  the  blood. 

Treatment. — The  use  of  actual  cautery  on  the  malignant  pustule  has  been 
recommended,  also  the  removal  of  the  whole  infected  area  and  neighboring 
lymphatics  with  the  knife.  Local  development  of  the  bacilli  is  said  to  be 
retarded  by  subcutaneous  injections  of  3  per  cent,  carbolic  acid  or  i :  1000 
corrosive  sublimate  repeated  two  or  three  times  a  day,  at  various  points  in 
the  neighborhood  of  the  pustule.  But  these  methods  cannot  be  regarded 
as  successful. 

On  the  other  hand,  there  is  much  evidence  that  no  surgical  intervention 
whatever  gives  the  best  results,  the  treatment  simply  consisting  of  main- 
taining the  general  health  and  protecting  the  local  lesion  by  aseptic  or 
antiseptic  dressings.  For  example,  Leland*  has  tabulated  the  cases  occur- 
ring at  the  Massachusetts  General  Hospital,  Boston,  during  the  past  36 
years.  These  records  show  23  cases:  7  of  these  were  operated  upon  and  3 
died  (42.8  per  cent.);  the  other  16  were  not  operated  and  all  recovered. 
Others  reporting  successful  non-operative  treatment  are:  Muskett  50  cases, 
Miiller  13  cases,  Remstedt  7,  and  Savini  5,  all  recovering,  Creite  13  recoveries 
and  I  death,  and  Graef  384  cases  with  20  deaths. 

Treatment  with  Sclavo's  serum  (page  167)  is  successfully  reported  both 
in  local  and  general  infections.  Thus  Italian  statistics  show  a  mortality  of 
6.09  per  cent,  of  the  treated  against  24.16  per  cent,  for  the  rest  of  Italy;  and 
in  England,  including  cases  already  moribund,  7.4  per  cent,  mortality  among 
the  serum-treated,  while  in  previous  years  (1889-1903)  without  serum  it  was 
26.5  per  cent.  In  some  cases  this  treatment  has  proved  successful  even  after 
anthrax  bacilli  have  invaded  the  blood. 

Prevention. — It  is  evident  from  the  foregoing  discussion  that  anthrax 
would  not  occur  in  certain  trades  if  all  dangerous  material  were  properly  dis- 
infected before  manipulation  by  the  workers.  To  accomplish  this  without 
injuring  the  product  for  its  intended  manufacturing  purpose  is  the  difi&culty 
not  yet  overcome  in  many  lines  of  industry.  Until  adequate  methods  of 
disinfection  are  perfected  and  enforced  other  means  of  prevention  must  be 
recommended. 

Dangerous  dust  should  be  drawn  from  the  sorting  tables,  etc.,  by  exhaust 
ventilation  downward  and  so  away  from  the  face  of  the  worker.  The  workers 
themselves  should  take  every  precaution  against  infection  according  to  their 
special  employment:  proper  clothing,  dust  masks,  strict  personal  cleanliness, 
hands  thoroughly  washed  before  handling  food,  meals  not  eaten  in  dangerous 
surroundings,  cuts  and  abrasions  carefully  protected,  hides  handled  with 
gloves  and  not  carried  against  bare  neck,  shoulders  or  arms. 

Preventive  inoculation  may  also  be  seriously  considered  for  workers  in 
the  dangerous  trades,  though  as  yet  statistics  are  not  available  along  these 
lines. 

*  Geo.  A.  Leland,  Jr.,  "The  Treatment  of  External  Anthrax."    To  be  published. 


172  OCCUPATIONAL   INFECTIOUS   DISEASES 

Legislation* — "In  order  to  minimize  the  danger  to  workmen,  sanitary 
measures  are  prescribed  by  law  in  a  number  of  European  countries,  for 
instance  in  England,  Germany,  France,  Belgium  and  Holland.  Fairly 
effective  legislation  on  anthrax  is  to  be  found  in  England  where  for  a  number 
of  years  the  government  factory  inspectors  have  had  the  valuable  cooperation 
of  the  Anthrax  Investigation  Board.  In  Germany  the  crusade  against 
anthrax  is  of  more  recent  origin;  statistics  are  being  kept  there  since  1910. 
Each  case  is  thoroughly  investigated  and  the  source  of  the  disease  is  traced 
as  far  as  possible.  In  both  countries  notices  are  posted  in  factories  calling 
attention  to  dangers  and  precautionary  measures. 

In  England  the  law  of  1901  referring  to  work  on  imported  hides  and  skins 
makes  provisions  for  keeping  the  workers'  food  and  clothing  in  a  clean  place. 
Water,  soap  towels  and  nail  brushes  must  be  furnished,  also  overalls  and 
gloves  if  dangerous  hides  are  handled.  Every  workman  having  an  open 
cut  is  required  to  report  immediately  to  the  foreman  and  to  leave  the  shop 
until  the  cut  is  healed.  Still  more  careful  regulations  are  prescribed  for 
work  on  hair  imported  from  Russia,  also  from  China,  Siberia  and  other 
Asiatic  countries.  Non-disinfected  material  must  be  kept  in  a  separate 
room  to  which  no  food  or  drink  may  be  taken.  Careful  rules  are  prescribed 
for  opening,  disinfecting  and  handling  materials  for  the  removal  of  dust  and 
for  personal  cleanliness.  The  precautionary  rules  of  Germany  and  France 
follow  very  closely  those  of  England." 

*  Since  this  chapter  was  written  the  editors  received  from  John  B.  Andrews  the  above 
summary  of  legislation  on  anthrax  and  also  some  of  the  statistics  on  anthrax  in  the 
United  States,  England  and  Germany  cited  on  page  169. 


SECTION  II 
PARASITES  AND  OCCUPATION 

BY  BAILEY  K.  ASHFORD.  M.  D.,  Porto  Rico 

Whatever  may  be  our  idea  of  what  should  constitute  "occupational 
diseases,"  it  is  undoubtedly  true  that  we  have  only  recently  begun  to  pro- 
tect that  most  humble  and  yet  most  important  of  all  laborers,  the  tiller  of 
the  soil.  The  diseases  to  which  he  is  by  reason  of  his  occupation  especially 
exposed,  malaria,  uncinariasis,  schistosomiasis,  amebic  dysentery,  filariasis 
and  ascariasis,  are  briefly  summarized  below.  As  our  National  tendency  is 
toward  the  speciahzing  of  labor,  toward  the  refinement  of  the  raw  product, 
toward  the  factory,  so  the  southern  countries  are  tending  toward  the  re- 
finement of  agriculture,  toward  the  production  of  the  largest  output  and 
highest  type  of  vegetable  life  where  soil  and  cHmate  best  favor  these  prod- 
ucts. But  just  as  it  was  impossible  to  build  a  Panama  Canal  until  the 
parasitic  J[oes  of  man  were  conquered,  so  will  it  be  impossible  to  reap  the  fullest 
harvest  from  tropical  and  subtropical  lands,  to  colonize  in  its  broadest  sense, 
until  we  learn  to  protect  ourselves  from  the  luxuriant  parasitic  life  which  is 
favored,  as  are  valuable  crops,  by  a  propitious  climate.  With  apologies  to 
those  who  consider  a  tropical  climate  per  se  an  obstacle  to  the  well-being  of 
the  white  man,  it  is  suggested  that  judgment  be  deferred  until  the  effect  of 
recent  sanitary  reforms  has  impressed  itself  upon  those  who,  living  in  warm 
climates,  seek  to  avoid  the  diseases  heretofore  considered  unavoidable. 
Indeed  many  so-called  "tropical  diseases"  might  better  be  termed  "rural 
diseases,"  so  extensive  also  is  their  domain  in  certain  country  districts  of 
the  temperate  zones.  Already  from  tropical  and  subtropical  lands  has 
sprung  the  efficient  prophylaxis  of  malaria,  responsible  for  the  agricultural 
depression  of  many  sections  of  our  south,  of  yellow  fever,  and  other  diseases 
which  wave-Hke  have  beaten  upon  our  shores,  and  have  even,  as  in  the  case 
of  "hookworm  disease,"  successfully  invaded  nearly  the  half  of  our  country 
in  so  subtle  a  form  as  to  have  been  unrecognized  for  probably  a  hundred 
years.  Thus  we  may  consider  the  tropics  as  the  original  home  of  most 
diseases  due  to  animal  parasites.  There  still  they  best  flourish  and  yield 
their  greatest  percentage  of  inefficiency  for  labor,  due  first  to  heat  and 
humidity  and  second  to  ignorance  of  modern  individual  hygiene,  upon 
which  all  true  State  and  National  hygiene  is  most  firmly  based.  The  essence 
of  sanitation  is  education  in  preventing  communicable  disease.  In  emer- 
gencies, imposed  by  force  of  law,  the  natural  evolution  of  sanitary  Hving 

173 


174  .  OCCUPATIONAL   INFECTIOUS   DISEASES 

must  ordinarily  spring  from  the  intelligent  cooperation  of  the  good  citizen 
whose  will  in  the  form  of  a  comprehensive  sanitary  organization  should 
control  the  ever-present  ignorant,  careless  or  criminal  spreader  of  disease 
and  death.  In  a  perusal  of  these  pages  it  will  be  seen  that  by  a  care- 
ful observance  of  the  very  simple  prophylaxis  of  two  notoriously  dangerous 
enemies  of  agricultural  countries,  malaria  and  uncinariasis,  we  go  far 
toward  exterminating  on  the  one  hand  dengue,  filariasis  and  yellow  fever, 
and  on  the  other,  typhoid  fever  and  the  dysenteries,  not  to  mention  other 
communicable  diseases  less  directly  affected. 


PROTOZOA 

Malaria. — An  infectious  disease  caused  by  the  introduction  into  the 
human  blood  through  the  bite  of  certain  anopheles  mosquitoes,  and  by 
them  alone,  of  the  sporozoites  of  one  of  three  species  of  hemosporidia — ■ 
Plasmodium  malarise,  Plasmodium  vivax  and  Laverania  malariae.  The 
ameboid  parasite  enters  the  erythrocyte,  transforming  its  hemoglobin  into  a 
black  pigment  "melanin,"  and  finally,  reaching  its  maximum  growth, 
sporulates,  liberating  its  daughter  cells,  or  "merozoites,"  to  attack  fresh  red 
cells.  In  rupturing  its  containing  cell  it  discharges  a  hemolysin  on  the  one 
hand  and  a  pyretogenous  toxin  on  the  other,  the  latter  provoking  the  t5^ical 
sequence  of  chill,  fever  and  sweat  with  their  clinical  accompaniments. 
The  predominant  brood  of  P.  malariae  is  Uberated  every  72  hours,  that  of 
P.  vivax  in  48  hours,  and  that  of  Laverania  malariae  in  24  to  48  hours,  these 
three  varieties  constituting  the  quartan,  tertian  and  aestivoautumnal  forms 
of  the  disease,  the  latter  being  the  tropical  and  most  dangerous  type.  Typic- 
ally there  is  an  intermittent  afebrile  period  between  each  brood,  but  in 
aestivoautumnal  fevers  this  period,  at  best  but  short,  may  be  merely  in- 
dicated by  a  remittance  if,  indeed,  a  most  irregular  or  continued  fever  be 
not  seen.  Craig  believes  in  two  varieties  of  aestivoautumnal  parasites, 
one  the  subtertian  the  other  the  quotidian.  As  the  antitoxin  of  the  host 
develops,  which  may  eventually  bring  about  a  cessation  of  symptoms,  game- 
tocytes  or  sexual  forms  appear  which,  ingested  by  a  fresh  mosquito  of  the 
proper  species,  undergo  development  therein  and  give  rise  to  infective  sporo- 
zoites in  about  2  weeks.  Sporulation  is  not  ordinarily  seen  in  the  periph- 
eral blood  in  infections  by  Laverania  malariae  but  in  the  internal  organs, 
especially  the  spleen,  hver  and  bone  marrow.  Here  in  these  filter-like  organs, 
as  well  as  in  the  brain,  intestines,  pancreas,  etc.,  the  parasited  erythrocytes 
damaged  by  the  toxin  tend  to  stick  to  the  walls  of  capillaries  likewise  affected 
and  cause  emboli  (Castellani  and  Chalmers)  which  are  productive  of  serious 
and  often  fatal  accidents.  All  forms  are  capable  of  producing  "pernicious 
malarial  fever,"  but  especially  L.  malariae,  i  per  cent,  of  aestivo-autuminal 
infections  forming  this  type.     Relapses  occur,  alleged  to  be  caused  by  the 


I 


PARASITES  AND   OCCUPATION  1 75 

return  to  asexual  activity  of  gametocytes  dormant  in  the  blood  and  internal 
organs,  especially  the  spleen  (latent  malaria).  Anything  tending  to  weaken 
the  acquired  relative  immunity  may  precipitate  an  exacerbation,  such  as 
excesses,  exposure  to  hot  sun,  fatigue,  etc.  Children  are  the  chief  reservoirs 
of  gametocytes,  and  from  the  examination  of  their  blood  and  spleen  Sir 
Ronald  Ross  constructs  with  other  factors  his  "endemic  index."  This 
latter  author  has  shown  that  when  the  number  of  anopheles  capable  of  trans- 
mitting malaria  is  reduced  below  a  certain  ratio  malaria  will  not  develop. 
The  necessary  factors  for  endemic  malaria  are  (i)  certain  anopheles  in  an 
active  state,  (2)  infected  persons,  and  (3)  individual  susceptibility.  Malaria 
is  not  found  usually  above  62  degrees  north  in  the  Eastern  and  45  degrees 
north  in  the  Western  Hemisphere.  Men  engaged  in  ditching  in  railway 
construction,  soldiers,  sailors  in  port  and  agricultural  laborers  in  infected 
districts  are  very  Hable  to  contract  malaria.  This  disease  in  all  time  has 
been  the  greatest  obstacle  to  colonization  of  the  tropics  by  the  white  race; 
it  has  transformed  fertile,  rich  and  populous  regions  into  lonely  wastes;  it 
has  rendered  the  development  of  valuable  natural  resources  impossible  and 
by  decimating  armies  has  defeated  the  highest  hopes  of  nations  in  critical 
struggles.  In  the  Canal  Zone  the  French  lost  22,000  with  an  average  work- 
ing force  of  10,000  laborers.  In  the  same  length  of  time  with  an  average 
force  of  33,000  we  have  lost  but  4000.  The  sanitation  of  the  Zone  cost  but 
about  $3.50  per  capita  of  population  per  annum  or  about  i  per  cent,  of  the 
total  expense  of  building  the  canal.  To-day  the  Zone  is  as  healthy  as  many 
northern  cities.  In  Havana  the  mortaHty  from  malaria  fell  from  350  a  year 
to  10,  and  yellow  fever  disappeared.  In  Rio  de  Janeiro  there  has  been  a 
fall  in  mortaUty  from  malaria  from  2235  in  1891  to  176  in  191 1,  and  from 
4456  deaths  from  yellow  fever  in  1891,  that  disease  disappeared  completely 
in  1908.  All  of  this  is  the  result  of  the  organized  application  of  modern 
prophylaxis. 

Prophylaxis. — There  are  four  essentials:  (i)  prevention  of  schizogony 
in  man  and  the  cure  of  all  infected,  (2)  prevention  of  mosquito  breeding,  (3) 
protection  of  man  from  their  bites,  (4)  education  of  the  public.  The  first 
is  accomplished  by  the  use  of  quinine.  The  second  may  be  divided  into  (c) 
removal  of  water  in  which  mosquitoes  breed,  {h)  rendering  water  unfit  for 
breeding.  Removal  of  water  is  best  carried  out  by  drainage,  and  tile  drains 
are  especially  effective  and  the  most  economical  in  the  long  run.  Where 
drainage  or  filling  is  impracticable  water  is  best  rendered  unsuitable  for 
breeding  by  covering  it  with  oil.  Larvicides  of  various  kinds,  Phinotas  oil, 
etc.,  may  also  be  used  efficiently.  One  ounce  of  crude  petroleum  to  15  sq. 
ft.  of  water  is  recommended  applied  not  less  than  once  in  2  weeks,  better 
once  a  week.  To  drainage  must  be  added  the  removal  of  mosquito  shelter 
(jungle  growth,  long  grass,  shrubbery,  etc.)  for  34  mile  from  habitations. 
Mosquito  brigades,  or  a  corps  of  men  whose  business  it  is  to  prevent  mosquito 
breeding  in  or  near  human  dwellings  by  the  prevention  of  water  collection 


176  OCCUPATIONAL    INFECTIOUS    DISEAS.ES 

in  little  pools,  in  old  cans,  depressions,  etc.,  is  a  valuable  adjunct.  Wire 
screens  to  windows  and  doors  are  of  great  value  in  excluding  the  mosquito, 
as  are  head  nets,  mosquito  bars,  etc.  The  mesh  should  not  be  less  than  16 
wires  to  the  inch.  The  gametocyte  population  should  be  segregated  and  all 
sick  of  malaria  isolated  and  screened.  In  the  Canal  Zone,  General  Gorgas 
depends  on  the  destruction  of  the  habitat  of  anopheles  within  200  yds.  of 
all  dwellings,  as  well  as  of  harbors  for  adults  (shrubbery,  long  grass,  etc.), 
screening,  the  use  of  crude  oil  in  temporary  pools  and  of  Phinotas  oil,  or 
copper  sulphate  for  grass  and  water  containing  algas.  The  supply  of  prophy- 
lactic quinine  to  those  who  will  voluntarily  take  it  is  an  important  method 
employed,  but  he  depends  on  draining  (especially  on  tile  under-drains)  for 
permanent  results.  He  considers  i)^  per  cent,  morbidity  an  indication  of 
an  improper  working  of  his  system.  For  prophylaxis  Koch's  method  of 
i-gram  doses  every  eighth  or  ninth  day  and  Celli's  method  of  0.4  daily 
are  the  most  popular. 

Treatment  of  Malaria. — Half  a  gram  of  quinine  every  3  hours  until 
parasites  disappear  is  sufficient.  It  should  be  followed  by  0.30  to  0.60 
a  day  for  a  week  thereafter,  and  subsequent  to  this  0.60  once  a  week  for  at 
least  2  months.  It  should  never  be  given  in  pill  or  tablet  form,  and  is  best 
administered  in  solution  with  yerba  santa  or  chocolate  syrup.  The  severe 
forms  may  require  hypodermic  injections  of  quinine  three  times  a  day  in 
3^-gram  doses,  better  intravenous  injections  of  even  larger  doses  well  diluted 
in  salt  solution.  Avoid  administering  quinine  in  the  height  of  an  attack  if 
possible.  Substitutes  for  quinine  are  unreliable.  Warburg's  tincture  is  of 
little  value  and  arsenic  of  less,  save  for  subsequent  anaemia. 

Amebic  Dysentery. — While  frequently  found  in  temperate  zones,  it  is 
really  an  endemic  of  the  tropics.  It  is  due  to  a  protozoon,  Entamoeba  his- 
tolytica, usually  from  25  to  40  microns  in  diameter,  with  a  clear  hyaline  re- 
fractive ectoplasm  and  a  finally  granular  endoplasm  containing  vacuoles, 
a  variable  nucleus  (best  studied  by  staining  with  Mallory's  iron  hematoxylin 
of  wet  fixed  smears  in  Schaudinn's  sublimate  alcohol),  and,  almost  constantly, 
red  blood  corpuscles.  Under  certain  conditions  it  becomes  resistant  with  the 
formation  of  a  cyst  containing  four  nuclei,  a  characteristic  which  is  responsible 
for  the  term  "E.  tetragena."  A  precystic  small  form  is  often  seen.  The 
parasite  enters  the  submucous  tissue  of  colon,  lower  ileum  and  rectum,  under- 
mining the  mucosa  and  producing  large  irregular  ulcers  usually  placed  at  right 
angles  to  the  bowel.  It  all  too  frequently  passes  by  way  of  radicles  of  the 
portal  vein  to  the  liver  where  it  sets  up  single  or  multiple  abscesses.  The 
majority  of  infections  are  liable  to  be  undiagnosed,  even  in  the  presence  of 
serious  lesions,  owing  to  latency  and,  frequently,  colorless  symptomatology. 
Accustomed  to  view  "dysentery"  as  a  disease  whose  syndrome  is  marked 
griping  and  tenesmus  with  frequent,  small,  muco-sanguinolent  stools,  the 
physician  is  often  unprepared  in  the  absence  of  the  acute  stage,  for  an  alter- 
nate looseness  and  constipation  of  the  bowels  without  marked  constitutional 


PARASITES   AND    OCCUPATION  1 77 

involvement.  The  practitioner  who  lacks  time  or  experience  for  the  com- 
paratively simple  distinction  between  entamoeba  coli,  a  harmless  commensal 
and  E.  histolytica,  should  refer  the  examination  of  the  stool  to  a  competent 
protozoologist.  Recently,  and  this  is  what  makes  correct  diagnosis  so  ex- 
tremely important,  we  have  been  furnished  by  Leonard  Rogers,  with  what 
bids  fair  to  be  accepted  as  a  true  specific  for  this  dangerous  and  insidious  dis- 
ease, emetine  hydrochloride.  James  has  just  recounted  degenerative  changes 
in  the  entamoebas  immediately  following  its  use  which  account  for  the  re- 
markable and  prompt  clinical  results.  Following  the  usual  treatment,  ab- 
solute rest,  liquid  diet,  preliminary  emptying  of  the  bowel  by  salts  or  oil,  and 
morphine,  3^^  grain  of  emetine  hydrochloride  is  administered  hypodermically 
three  times  a  day  for  2  or  4  days.  It  has  been  objected  that  the  entamoebae 
do  not  always  disappear  under  this  treatment,  but  the  writer  can  testify  to 
almost  uniformly  favorable  clinical  results.  James  counsels  the  use  of  9 
to  12  grains  in  as  short  a  time  as  possible,  compatible  with  individual  toler- 
ance, to  forestall  relapses.  A  daily  dose  of  from  2  to  4^^  grains  can  be  reached 
in  3  days.  This  treatment  should  be  followed  by  a  heaping  teaspoonful  of 
bismuth  subnitrate  every  3  hours,  which  usually  causes  prompt  disappearance 
of  the  parasite,  and  is  supposed  to  deprive  it  of  certain  substances  necessary 
for  its  nutrition  by  combining  with  sulphur  in  the  intestinal  canal.  The 
prophylaxis  consists  in  the  avoidance  of  contaminated  drinking  water,  raw 
vegetables  and  fruits.  Sight  should  not  be  lost  of  the  fact  that  certain 
authorities  believe  that  it  is  in  part  if  not  wholly  a  contact  infection. 


NEMATODES 

Uncinariasis. — This  is  an  infectious  disease  caused  by  the  presence  in  the 
small  intestine  of  man  of  a  sufficient  number  of  adult  nematodes  of  the  sub- 
family Uncinariinae,  species  Anchylostoma  duodenale  and  Necator  Ameri- 
canus,  to  overcome  his  relative  racial  or  individual  resistance.  The  worm, 
from  3-^  to  ^^  in.  long  and  of  the  thickness  of  a  pin  sinks  its  buccal  armature 
into  the  intestinal  mucosa  causing  solution  of  continuity  for  the  admission 
of  bacteria  and  at  times  local  hemorrhage,  feeds  upon  the  epithelium  and  pro- 
duces a  hypothetic  toxic  substance  probably  responsible  for  many  clinical 
features  of  the  disease.  The  ova  do  not  hatch  in  the  body  of  the  host  but, 
passed  with  the  feces  upon  a  damp  soil,  at  a  favorable  temperature  evolve 
into  ensheathed  larvse  which  infect  a  new  host  by  penetration  of  the  sound 
skin,  usually  of  bare  feet,  causing  "ground-itch."  From  this  point  they 
migrate  to  their  site  of  election  in  the  jejunum.  The  infective  larvae  are 
usually  found  upon  the  soil  in  little  nests,  larger  than,  but  corresponding  to, 
the  site  polluted  by  ova-bearing  feces.  In  endemic  areas  of  the  tropics  and 
subtropics  there  is  perennial  infection  of  agricultural  laborers.  In  temperate 
zones,  in  mines  and  tunnels,  and  in  the  summer  throughout  farming  districts, 


178 


OCCUPATIONAL   INFECTIOUS    DISEASES 


PARASITES    AND    OCCUPATION 


179 


Fig.  3. — Stages  of  Development  of  Ovum  of  Negator  Americanus. 

Microphotographs  by,  Dr.  Wm.  Gray,  Army  Medical  School  of  sections  belonging  to 
Major  B.  K.  Ashford,  member  of  the  late  Porto  Rico  Anaemia  Commission. 


i8o 


OCCUPATIONAL   INFECTIOUS    DISEASES 


intensity  of  infection  is  only  measured  by  the  amount  of  surface  pollution 
by  ova-containing  feces.  Infected  soil  seems  to  become  relatively  in- 
nocuous after  6  months  freedom  from  pollution.  Shaded,  moist  soil  in 
warm  weather  and  density  of  population  in  a  barefooted  people  who 
directly  pollute  the  surroundings  of  their  homes  and  their  place  of  work  are 
the  determining  factors  in  producing  severe  endemics,  given  introduction 


Fig.  4. — Photograph  of  a  patient  of  the  Institute  of  Tropical  ^Medicine  and  Hygiene 
of  Porto  Rico  suffering  from  uncinariasis  intense  grade;  hemoglobin  14  per  cent.,  erythro- 
cytes* 751,000,  leucocj^tes  17,000,  case  of  several  years  standing.  Photograph  furnished  by 
Major  Bailey  K.  Ashford. 

of  carriers.  When  larvae  nests  are  few  and  far  between,  and  ova  deposited 
by  carriers  are  scarce,  a  low  endemic  index  may  be  reached  capable  only 
of  producing  carriers  and  even  these  quite  accidentally.  Regions  thus 
lightly  infected  may  become  dangerous  foci  if  their  density  of  population 
is  considerably  increased  by  an  unsanitary  laboring  class.  Shoes  are  not 
always  an  efficient  protection,  as  they  are  often  flooded  by  muddy  water. 
Light  infections  produce  few  or  no  symptoms,  at    best  debility  and  disin- 


PARASITES   AND    OCCUPATION  l8l 

clination  for  work,  with  a  little  dyspepsia  and  faint  pallor.  From  such  light 
cases  we  may  proceed,  as  subsequent  reinfections  are  superadded,  to  the 
very  gravest  forms  of  anemia,  accompanied  by  an  effacement  of  character 
and  energy  and  retarded  mental  reaction  quite  peculiar  to  the  disease.  The 
best  treatment  is  the  weekly  administration  of  thymol,  based  on  an  adult 
dosage  of  4  grams,  in  capsules,  2  grams  at  8  and  2  at  10  A.M.  on  an  empty 
stomach,  preceded  the  night  before  by  a  light  supper  and  a  purge  and  fol- 
lowed at  noon  by  a  purgative  dose  of  sodium  sulphate.  After  three  such 
doses  the  patient  may  feel  reasonably  sure  of  a  cure  of  his  disease  as  he 
will  have  usually  expelled  over  nine-tenths  of  his  parasites,  but  persistent 
thymolizing  may  be  required  to  rid  him  of  all.  Necator  Americanus  will 
not  be  ordinarily  expelled  by  filix  mas,  the  preferred  anthelmintic  in  Europe. 
Betanaphthol  in  2-gram  doses  may  be  administered  as  recommended  for 
thymol. 

Prophylaxis.- — Uncinariasis  is  to-day  one  of  the  most  serious  obstacles 
to  agricultural  labor  in  the  world's  tropical  and  subtropical  belt.  Indeed, 
much  of  the  "chronic  malaria"  of  our  South  is  uncinariasis.  It  has  threat- 
ened the  completion  of  tunnels  and  terminated  mining  operations;  it  has 
empoverished  not  only  agricultural  laborers  but  their  employers;  it  has  laid 
a  benumbing  hand  on  the  growing  country  youth  and,  at  times,  it  has  been 
largely  responsible  for  the  poverty,  ignorance  and  invalidism  of  a  full  four- 
fifths  of  the  working  classes  of  an  entire  country.  The  control  of  uncinariasis 
depends  first  on  education  in  individual  hygiene,  second  on  the  treatment  of 
worm-sick,  and  third  and  least  efficacious,  on  sanitary  law.  The  first  two 
are  best  served  by  the  free  rural  dispensary.  As  the  Porto  Rico  campaign 
was  the  first  of  its  kind  and  has  served  as  a  basis,  at  least  in  part  for  subse- 
quent ones  in  other  countries,  including  our  own,  we  will  refer  to  its  results. 
The  hemoglobin  percentage  of  579  country  people  averaged  43.09  before 
treatment  in  1904.  In  19 13  after  the  treatment  of  about  one-half  the  island 
population  of  a  million,  the  examination  of  579  of  the  same  ty^t  of  people 
rendered  an  average  of  72.22  per  cent,  hemoglobin.  As  the  hemoglobin 
percentage  is  roughly  equivalent  to  percentage  of  efficiency  for  labor,  it  can 
be  truthfully  said  that  treatment  and  education  alone  have  raised  the  laboring 
efficiency  of  the  working  class  by  nearly  68  per  cent.  By  far  the  greatest 
effect  has  been  from  treatment,  for  although  shoes  are  more  generally  worn, 
privies  are  still  scarce  enough.  The  sanitary  privy  is  the  finahty  toward 
which  all  work  should  tend. 

Filariasis. — The  term  usually  signifies  a  condition  accompanying  the 
presence  in  the  lymphatic  system  of  man  of  a  hair-like  nematode  worm, 
Filaria  Bancrofti,  whose  embryos  or  microfilariae  appear  in  the  blood. 
These  cylindrical  and  ensheathed  embryos,  with  blunt  anterior  and  sharp 
posterior  extremities,  are  7  to  8  microns  in  diameter  and  300  microns  long, 
moving  in  graceful  curves  among  the  erythrocytes.  Normally  herding  in 
the  profoundest  depths  of  the  circulatory  system  by  day,  they  invade  the 


l82  OCCUPATIONAL   INFECTIOUS    DISEASES 

peripheral  vessels  by  night,  probably  to  better  gain  their  intermediate  host, 
certain  species  of  culex  and  anopheles  mosquitos.  In  the  stomach  of  this 
insect  their  sheath  is  hemolyzed  and,  penetrating  its  wall,  they  develop  in 
the  muscles  of  its  thorax,  finally  reaching  labium  and  palps.  When  the  mos- 
quito thrusts  its  probosis  into  man,  they  escape  by  rupture  of  the  distended 
tissue  in  which  they  are  confined  and  enter  the  skin  through  the  puncture  as 
well  as  the  unbroken  surface  in  its  vicinity.  The  parasite  is  generally  dis- 
tributed throughout  certain  districts  of  intertropical  regions  with  a  decided 
preference  for  hot  lowlands.  The  typical  lesion  is  a  varix  of  lymphatics  set 
in  fatty  tissue,  and  the  seat  of  recurrent  lymphangitis.  Frequently  localized 
in  the  vicinity  of  the  external  genitals  the  extreme  may  be  reached  by  the 
formation  of  a  huge  varix  involving  the  glands  and  tributary  vessels  of  the 
abdominal  and  pelvic  lymphatics.  To  Hanson's  theory  of  mechanical 
obstruction  of  lymph  channels  by  adults,  embryos  and  immature  ova  should 
be  added  a  lymphangitis  by  the  repeatedly  awakened  virulence  of  some  strain 
of  streptococcus,  alone  or  in  symbiosis  with  other  bacteria  among  which  may 
be  mentioned  Le  Dantec's  dermatococcus,  or  Dufougere's  lymphococcus. 
Clinically  we  recognize:  (i)  Endemic  lymphangitis  with  red,  tender  lines  in 
the  course  of  certain  lymphatics,  inflammation  of  the  receiving  glands, 
severe  pain  and  a  sharp  constitutional  febrile  reaction.  Bubonic  plague 
may  at  times  be  simulated  and  death  occur.  Of  serious  prognosis  is  intra- 
abdominal or  intrathoracic  abscess,  an  unusual  complication.  (2)  Lymphatic 
tumors.  Adenolymphocele,  generally  at  the  base  of  Scarpa's  triangle,  has 
the  feel  of  a  mass  of  soft  rubber  tubes  and  may  be  confused  with  hernia, 
lymphadenoma  and  lipoma.  Pedunculated  inguino-scrotal  lymphangioma 
has  only  a  superior  pedicle  and  exactly  simulates  hernia;  when  inflamed,  a 
strangulated  hernia.  (3)  Lymphatic  varicocele  and  testicular  lesions.  Acute 
filarial,  often  misnamed  "malarial"  orchitis,  often  causes,  as  do  inflamed 
lymphatic  varicocele  and  adenolymphocele,  pseudorenal  colic,  a  pitfall  for 
the  unwary  tropical  practitioner.  Lymph  scrotum,  a  cutaneous  and  subcu- 
taneous infiltration  is  generally  accompanied  by  hydrocele,  often  with  thick- 
ened cartilaginous-like  tunica  vaginalis  and  a  permanently  damaged  testicle 
and  epididymis.  (4)  Lymphorrhagias.  Chyluria  is  the  emission  of  milky, 
greasy  urine,  and  hematochyluria  the  passage  of  chylous  urine  mixed  with 
blood.  The  pathologic  basis  for  this  phenomenon  is  the  dilatation  of  the 
lumbo-sacral  lymphatics  with  back  flow  into  the  lymph  vessels  of  kidney, 
ureter  and  bladder.  The  attacks  are  usually  irregular  and  embryos  are  apt 
to  be  found  only  in  the  first  emissions  of  chylous  urine.  Lymphorrhagia 
externa  is  best  seen  on  pricking  a  bulla  of  a  lymph  scrotum  which  allows  the 
gradual  filtration  of  quantities  of  lymph.  (5)  Elephantiasis.  The  skin  is 
typically  rough,  tough,  hard,  covered  with  tubercles  and  often  greasy.  On 
section  it  is  either  like  bacon  rind,  below  which  lies  a  yellowish  gelatinous 
substance  filling  the  connective-tissue  spaces,  or  more  fibrous,  creaking  under 
the  knife.     Such  elephantoid  tissue  in  marked  cases  hangs  in  huge  folds  and 


PARASITES   AND    OCCUPATION  1 83 

resembles  elephant  hide.  This  is  the  final  result  of  a  chronic  filarial  lymph- 
angitis, often  aggravated  by  acute  attacks.  The  parts  usually  affected 
are  the  leg,  foot  and  scrotum,  but  penis,  labia  majora,  breasts,  forearms  and 
hands  are  not  exempt.  Some  of  these  skin  tumors  are  enormous,  causing 
great  deformity  and  even  preventing  locomotion. 

Treatment. — There  is  no  specific.  Salvarsan,  atox}d  and  other  arsenic 
preparations  are  useless.  Filarial  lymphangitis  with  its  dependent  end- 
products  is  best  treated  by  removal  to  a  northern  cHmate.  When  acute, 
ice  locally  with  complete  rest  in  bed  and  appropriate  symptomatic  medica- 
tion is  all  that  can  be  recommended.  Ichthyol  locally  seems  to  be  of  value. 
Extreme  caution  is  necessary  in  dealing  surgically  with  lymphatic  tumors. 
They  are  most  apt  to  become,  septic  and  are  usually  only  a  part  of  an  exten- 
sive and  hidden  mass  in  the  pelvis.  Castration  for  filarial  orchitis  is  usually 
unjustifiable.  Elephantiasis  is  best  treated  by  elevation,  compression,  a 
daily  course  of  30  to  90  hypodermic  injections  of  2  cc.  of  a  10  per  cent,  solu- 
tion of  fibrolysin  and  perhaps,  if  needed  thereafter,  the  excision  of  skin  strips. 
In  the  scrotum,  vulva,  etc.,  extensive  removal  and  adjusting  of  healthy  skin 
flaps  is  the  best  procedure.     The  prophylaxis  is  as  for  malaria. 

Trichinosis. — Due  to  Trichinella  spiralis,  a  nematode  which  passes  its 
entire  life  cycle  in  man,  rat  and  hog.  The  parasite  is  ubiquitous,  but  es- 
pecially common  among  sausage  makers.  The  larvae  encysted  in  the  muscles, 
when  the  flesh  is  ingested,  become  mature  worms  whose  embrj^os  penetrate 
the  intestinal  wall  and  again  reach  the  muscles.  The  chief  reservoir  of 
trichineUa  spiralis  is  the  rat,  which  feeds  on  its  kind  and  on  scraps  of  infected 
hog  flesh  and  on  infected  feces.  Severe  infections  cause  in  man  two  stages 
of  the  disease;  first  a  gastro-intestinal,  and  second  a  constitutional,  with 
intense  muscular  pains,  oedema,  a  sharp  febrile  reaction  and  eosinophilic 
leucocytosis. 

Treatment. — Smart  purging  in  the  first  stage  or  santonin  and  calomel. 
The  treatment  of  the  second  stage  is  symptomatic. 

Prophylaxis. — Meat  inspection  is  impracticable  as  an  efficient  pro- 
phylactic measure.  The  larvas  die  after  cooking  at  a  temperature  over  i6o°F. 
or  long-continued  pickHng.  This  is  another  argument  besides  plague 
for  a  rat  warfare,  especially  in  slaughter-houses,  meat  shops  and  the  vicinity 
of  hog  pens.  Hogs  should  not  be  fed  on  waste  from  salughter-houses,  and 
should  be  kept  away  from  privies. 

Ascaris  Lumbricoides. — A  white  or  rose-colored  cyHndrical  worm,  15 
to  30  cm.  long  with  a  diameter  of  from  4  to  8  mm.  The  anterior  extremity 
is  blunt;  the  posterior  pointed.  The  sexes  are  separate  and  the  ova  are 
eUipsoid,  50  to  75,  by  40  to  50  microns,  brown  or  amber-colored  with  two 
envelopes,  the  internal  smooth  and  resistant,  the  external  mammillated  and 
easily  detached.  Habitat,  small  intestine  of  man.  It  is  ubiquitous.  There 
is  no  intermediary  host,  the  ova  developing  after  15  days  in  water,  but,  being 
very  resistant,   they  may  reach  maturity  even  after  5  years  (Lecomte). 


184  OCCUPATIONAL   INFECTIOUS    DISEASES 

While  not  mentioned  in  connection  with  occupations  in  the  temperate 
zones,  in  the  tropics  it  is  exceedingly  common  among  agricultural  laborers 
from  the  use  of  fruits  and  raw  vegetables.  The  recent  investigation  of  the 
Institute  of  Tropical  Medicine  of  Porto  Rico,  19 13,  shows  it  to  be  the  prevail- 
ing intestinal  parasite  of  the  coffee  laborers,  about  90  per  cent,  of  10,140 
persons  of  all  ages  and  both  sexes  being  infected.  As  clinical  studies  of 
these  cases  were  made,  it  is  interesting  to  note  that  no  uniformly  bad  effects 
can  be  attributed  to  the  very  heavy  infections  seen.  At  times  gastro-in- 
testinal  disturbances  were  noted,  even  entero-colitis.  The  elaborate  train 
of  nervous  symptoms  usually  described  were  as  a  rule  conspicious  by  their 
absence.  There  are  at  least  two  serious  aspects  to  ascariasis;  (i)  the  tendency 
to  upward  wandering,  causing  vomiting  of  worms,  penetration  into  the  gall 
ducts  and  even  into  the  liver,  perforation  of  the  bowel,  generally  through  a 
preexisting  ulcer,  etc.;  and  (2)  intestinal  obstruction.  In  a  small  number  of 
cases,  however,  the  worm  undoubtedly  acts  as  a  local  irritant  even  to  the 
extreme  of  simulating  appendicitis  or  gastro-entero-colitis,  and  of  indirectly 
producing  profound  nervous  disturbances,  or  a  cachectic  condition. 

Treatment. — We  are  accustomed  to  give  i  centigram  of  santonin  for 
each  year  to  25  years  of  age,  combined  with  an  appropriate  dose  of  calomel. 
This  is  administered  at  bedtime  in  two  doses,  2  hours  apart,  after  a  day  of 
fasting,  and  followed  next  morning  by  a  dose  of  castor  oil.  Great  caution  is 
recommended  in  using  this  drug  as  dangerous,  if  not  fatal,  accidents  occur  in 
young  children.  Usually  it  is  a  safe  remedy,  but  somewhat  undependable. 
Neither  Trichuris  trichiura  nor  Strongyloides  stercoralis  seems  ordinarily  to 
be  definite  factors  in  the  causation  of  disease.  The  Institute  of  Porto  Rico 
finds  the  first  a  very  common  parasite  in  man.  Said  to  cause  colitis,  marked 
anemia,  and  nervous  symptoms,  we  have  never  been  able  to  incriminate  this 
worm.  It  is  difficult  to  expel,  but  thymol  is  sometimes  successful.  Strongy- 
loides stercoralis  is  less  common  in  Porto  Rico  but  not  rare.  It  does  not 
seem  to  cause  diarrhea  as  reported  by  other  authors,  but  infections  may 
not  have  been  heavy  enough.  It  is  especially  found  in  brickyard  workers, 
miners'  tunnel  workers  and  barefooted  agricultural  laborers  as  its  mode  of 
infection  is  similar  to  that  of  uncinariasis.  The  embryo,  not  the  ovum,  is 
what  is  usually  found  in  the  feces. 

Cestodes. — T^nia  saginata  frequently,  and  T.  solium  much  less  com- 
monly are  found  in  these  who  eat  insufficiently  cooked,  or  even  raw  beef 
or  pork,  such  as  butchers,  cooks,  and  sausage  makers.  These  parasites  are 
ubiquitous,  but  are  rare  where  meat  inspection  and  a  proper  disposal  of 
excrement  are  exacted.  Among  Porto  Rican  agricultural  laborers,  where  meat 
is  rarely  consumed  and  always  well  cooked,  our  Institute  of  Tropical  Medicine, 
in  nearly  10,000  nematode  infections  studied  in  1913,  failed  to  find  one  case 
of  teniasis.  Taenia  saginata,  4  to  18  meters  long,  is  a  white  flat  worm  with 
an  unarmed  head  and  about  1000  hermaphroditic  segments  (proglottides) 
each  containing  a  uterus  with  from  25  to  35  lateral  branches.     Taenia  solium, 


PARASITES    AND    OCCUPATION  185 

2  to  3  meters  long,  has  a  double  row  of  hooks  upon  its  rostellum  and  each 
proglottis  contains  a  uterus  with  from  7  to  10  lateral  branches.  The  ova, 
ingested  by  cattle  (T.  saginata)  and  by  hogs  (T.  solium),  develop  into 
embryos  which  finally  encyst  in  their  flesh,  forming  cysticercus  bovis  and 
cysticercus  cellulosae  respectively.  The  habitat  of  the  mature  worms  is 
man's  intestine  which  they  never  perforate,  and  from  which  they  rarely 
wander.  There  is  little  doubt  but  that  a  tape-worm  infection  may  be  and 
frequently  is  compatible  with  apparent  health  but  in  the  feeble  symptoms 
are  more  apt  to  arise,  usually  those  of  a  gastro-intestinal  dyspepsia  often 
with  boulimia  and  obscure  nervous  manifestaticns  generally  limited  to  nasal 
and  anal  pruritus,  dry  cough,  vertigo  and  cardiac  palpitation.  Occasionally 
the  cysticercus  stages  of  T.  solium  is  passed  in  the  tissues  of  man,  and  as 
these  cysts,  0.006  to  0.020  mm.  long,  at  times  invade  the  eye  and  brain  the 
prognosis  is  extremely  grave.  Whatever  tenifuge  be  selected  the  patient 
should  (i)  take  the  drug  on  an  empty  stomach,  and  (2)  follow  up  the  last 
dose  within  a  half  hour  by  a  vigorous  purge  to  expel  the  stunned  worm. 
Three  drugs  are  worthy  of  special  mention:  (i)  pelletierin  tannate,  preemi- 
nently effective  but  dangerous,  (2)  male  fern,  given  with  calomel  in  i^^-gram 
capsules  of  the  etheral  extract,  two  every  10  minutes  to  6  or  8  grams,  and, 
(3)  thymol  as  recommended  for  uncinariasis.  WTiere  toxicity  is  feared 
pumpkin  seed,  kousso  or  the  expressed  juice  of  cocoanut  meat  may  be 
employed.  The  prophylaxis  consists  in  treatment  of  all  infected,  strict 
national  and  international  meat  inspection,  and  proper  disposal  of  human 
feces. 

TREMATODES 

Schistomiasis. — Caused  by  Schistosoma  hematobium,  whose  terminal 
spined  ova  produces  a  serious  inflammation  of  the  urinary  tract  with  bleeding 
papillomatous  granulation  tissue,  chiefly  of  the  bladder  wall,  notably  among 
the  Fellaheen  of  the  lower  Nile  who  work  in  the  fields  up  to  their  knees  in 
water;  by  S.  japonicum,  encountered  in  the  far  East  and  causing  grave 
hepatic  and  intestinal  lesions  often  leading  to  cachexia  and  death;  and  by  S. 
mansoni,  the  parasite  responsible  for  American  Schistosomiasis.  In  the 
latter  disease,  common  in  the  West  Indies  and  South  America  the  histo- 
pathology  is  similar  to  that  caused  by  S.  hematobium  but  the  lesions  are 
found  in  the  colon  and  rectum.  The  ova  are  all  lateral  spined  and  contain 
a  miracidium  which  liberated  in  water  infect  through  the  skin,  according  to 
Looss,  without  the  intervention  of  an  intermediate  host.  In  the  series  of 
10,140  cases  of  the  Institute  of  Tropical  Medicine  of  Porto  Rico,  1913, 
over  200  were  found  to  be  infected,  very  few  of  whom  showed  definite  symp- 
toms save  a  suspicious  epigastric  pain.  These  patients  all  gave  a  history  of 
having  bathed  in  a  river  suspected  of  being  contaminated.  Heavier  infections 
cause   "Schistosoma   dysentery,"   a  proctitis    roughly   simulating    chronic 


J 85  OCCUPATIONAL   INFECTIOUS    DISEASES 

dysentery,  but  with  a  tendency  to  prolapse  of  the  rectum.  The  prognosis 
is  generally  favorable  in  light  infections,  but  treatment  is  f utHe.  The  prophy- 
laxis is  generally  complete  if  one  avoids  bathing  or  wading  in  infected  streams 
and  the  ingestion  of  unboiled  water  or  contaminated  fruits  and  vegetables. 
In  Porto  Rico  we  are  not  prepared  to  consider  Looss'  theory  of  skin  infection 
as  proven. 


CHAPTER  III 
COMPRESSED-AIR  ILLNESS 

BY  SEWARD  ERDMAN.  M.  D..  New  York  City,  N.  Y. 

Synonyms. — "Caisson  disease,"  "divers'  palsy,"  "bends,"  "screws," 
"courbatures,"  "aeropathy,"  "aeraemia." 

Definition. — An  occupational  disease  occurring  among  divers,  caisson 
workers,  subaqueous  tunnel  workers,  etc.,  following  exposure  to  compressed 
air,  the  symptoms  of  which  arise  only  after  the  too  rapid  removal  of  pressure 
(decompression),  which  liberates  in  the  supersaturated  body  fluids  and 
tissues  bubbles  of  gas. 

The  symptoms  are  usually  of  sudden  onset  within  from  15  minutes  to  a 
few  hours  after  decompression,  and  include  pains,  paralyses,  dyspnoea,  and 
even  circulatory  failure  and  death. 

There  is  a  strong  tendency  to  early  and  spontaneous  recovery  in  the 
majority  of  cases. 

Historical. — Descriptions  of  compressed-air  illness  date  back  only  75 
years  and  it  is  essentially  a  disease  of  modern  civilization. 

In  1839  Triger,  a  French  engineer,  who  elaborated  the  first  practical  cais- 
son and  employed  it  in  mining  coal  under  the  River  Loire,  describes  the  oc- 
currence of  pains  in  the  extremities  of  certain  of  his  caisson  workers,  and  these 
observations  constitute  the  earliest  authentic  recognition  of  compressed-air 
illness. 

However,  from  the  times  of  Alexander  the  Great  and  Aristotle  onward 
through  the  centuries,  crude  diving  bells  and  helmets  had  been  experi- 
mented with,  and  in  1665  salvage  from  the  sunken  Spanish  Armada  was 
accomplished  at  the  depth  of  46  ft. 

In  1717  Halley  devised  a  diving  bell  which  could  be  used  at  a  depth  of 
60  ft. 

A  century  later  Siebe,  in  1819,  devised  the  first  diving  helmet  supplied 
with  air  from  an  air  pump,  and  this  diving  dress  which  he  perfected  in  1837 
is  the  prototype  of  those  now  in  use. 

The  principle  of  the  caisson  was  patented  by  Cochrane  in  1830  but  first 
made  a  working  device  by  Triger. 

Doubtless  in  the  earlier  experiments  technical  difl&culties  prevented  ex- 
posure to  sufficient  pressures  for  a  sufficient  time  to  give  rise  to  symptoms 
of  compressed-air  illness. 

Scientific  investigation  of  caisson  disease  was  earliest  undertaken  by  Pol 
and  Wattelle^  in  1854,  and  although  the  mechanical  pressure  theory  which 

187 


1 88  SPECIFIC    OCCUPATIONAL   DISEASES 

they  put  forward  has  since  been  entirely  rejected,  nevertheless  many  of  their 
observations  and  conclusions  have  remained  uncontroverted. 

In  1857  F.  Hoppe-Seyler,  repeating  the  experiments,  which  Boyle  had 
begun  in  1670,  upon  animals  subjected  to  rarefied  atmosphere  by  use  of  the 
vacuum  pump,  confirmed  the  fact  of  the  liberation  of  bubbles  of  gas  in  the 
body  fluids. 

By  analogy,  Hoppe-Seyler  propounded  the  correct  theory  of  the  causation 
of  caisson  disease. 

P.  Bert^  in  1878,  by  the  first  animal  experiments  with  compressed  air, 
proved  conclusively  the  truth  of  Hoppe-Seyler's  theory,  and  his  work  is  still 
regarded  as  a  classic  in  the  literature  of  compressed-air  illness. 

Most  valuable  experimental  work  and  contributions  to  the  study  of  this 
disease  are  to  be  attributed  to  such  men  as  Heller,  Mager,  von  Schr otter,  ^ 
Silberstern,^'*  Hill,^-  Greenwood,  Macleod,^^  Haldane,  Boycott,  Damant  and 
to  numerous  others. 

The  building  of  the  East  River  tunnels  from  New  York  to  Long  Island 
City  for  the  Pennsylvania  R.  R.  in  1906-1909  afforded  material  for  mono- 
graphs by  F.  L.  Keays,*  H.  Japp,^^  McWhorter^"  and  the  writer,^"^^  dealing 
chiefly  with  the  practical  and  clinical  aspects  of  the  illness. 

Frequency. — Occurrence  of  this  disease  postulates  the  use  of  compressed 
air,  and  consequently  its  frequency  has  greatly  increased  with  the  develop- 
ment of  submarine  construction  work  and  diving. 

Caisson  work  for  the  Kehl  bridge  over  the  Rhine  in  1859  was  one  of  the 
earlier  large  ventures.  The  St.  Louis  bridge,  1870,  and  the  Brooklyn  bridge, 
1873,  also  the  Danube  bridge,  1890,  afforded  opportunities  for  the  further 
study  of  caisson  disease. 

However,  river-tunnel  construction  employs  so  many  more  men  in  com- 
pressed air  than  does  caisson  work  that  we  turn  to  those  larger  enterprises 
to  furnish  the  massive  statistics  for  a  clinical  study. 

The  East  River  tunnels  employed  over  10,000  men  during  their  con- 
struction, at  an  average  working  pressure  of  -{-32  lb.  with  a  maximum  of 
+42  lb. 

The  writer^  has  reported  on  i  year's  work,  and  F.  L.  Keays,^  the  medical 
director,  has  ably  analyzed  the  total  statistics  which  embrace  3692  cases  of 
illness  among  the  10,000  men,  or  36.9  per  cent.  But  I  feel  certain  that  if 
every  trivial  case  of  "bends"  had  been  recorded,  the  percentage  would  have 
to  be  doubled;  indeed  I  doubt  that  even  10  per  cent,  escaped  unscathed  at 
all  times. 

At  the  Eider  bridge  in  1885,  with  a  maximum  pressure  of  -f35  lb.,  there 
occurred  380  cases  among  140  workers,  or  270  per  cent. 

There  were  reported  320  cases  among  675  men  who  worked  at  the  Danube 
bridge  in  1890  at  a  maximum  pressure  of  +32)^^  lb.,  and  this  represents 
47.4  per  cent. 

But  as  the  possibility  of  the  development  of  symptoms  is  present  every 


COMPRESSED-AIR   ILLNESS  1 89 

time  the  pressure  is  removed,  comparison  with  the  number  of  man  shifts 
would  be  a  more  accurate  method  of  estimating  the  frequency  of  the 
disease. 

Thus,  at  the  East  River  tunnels  there  were  557,000  decompressions,  and  the 
3692  cases  of  illness  would  give  an  incidence  of  only  0.663  P^^  cent. 

The  British  Admiralty  Committee  on  Deep  Sea  Diving  reported  60,000 
decompressions  with  577  cases,  or  0.96  per  cent. 

General  Discussion  of  the  Nature  of  Compressed-air  Illness,  Based  on  the 
Accepted  Gas-buhble  Theory. — When  a  man  or  an  animal  is  exposed  to 
compressed  air,  the  blood,  by  diffusion  from  the  alveoli,  and  later  all  the 
body  fluids  and  tissues  become  supersaturated  with  the  nitrogen  of  the 
atmosphere  to  a  degree  dependent  upon  three  factors:  (i)  the  amount 
of  pressure  (see  Dalton's  law);  (2)  the  length  of  exposure  to  the  pressure; 
(3)  the  vascularity  and  the  absorptive  ability  of  the  individual  tissues. 

Upon  decompression  the  excess  nitrogen  (see  below)  tends  always  to 
flow  off  from  the  supersaturated  tissues,  by  means  of  the  circulating  blood, 
into  the  alveoli  and  expired  air  where  the  pressure  is  lower. 

Such  a  gradual  and  orderly  desaturation  of  the  body  tissues  would  occur 
under  favorable  conditions  without  the  ebullition  of  any  bubbles  of  free 
gas,  and  no  symptoms  would  then  result. 

As  will  be  shown,  however,  the  desaturation  of  the  tissues  always  lags 
behind  the  lowering  of  pressure,  as  decompression  is  commonly  practised, 
and  there  is  left  a  residuum  of  gas  in  the  organism. ^^ 

Therefore  it  follows  that  there  is  always  the  possibility  that  too  rapid 
removal  of  pressure  may  result  in  the  freeing  of  nitrogen  in  the  form  of 
bubbles  in  the  tissues  and  body  fluids. 

Probably  if  the  bubbles  be  small  in  size  and  amount  and  occur  in  in- 
different tissues,  the  circulation  will  get  rid  of  them  by  way  of  the  lungs  and 
still  no  symptoms  may  arise. 

When  free  bubbles  of  gas  by  their  expansion  or  coalescence  form  gas 
emboli  in  the  circulation,  or  inflict  direct  mechanical  injury  upon  delicate 
nervous  tissue  by  expansion  of  the  bubbles  in  accordance  with  Boyle's  law, 
then  symptoms  may  and  do  result. 

Fat,  fluids,  and  nerve  tissue  are  especially  affected;  consequently  the 
irritation  of  peripheral  nerves,  or  injury  to  the  central  nervous  system  by 
interference  with  its  blood  supply  and  by  pressure  of  expanding  bubbles, 
will  give  rise  to  many  of  the  protean  symptoms  which  characterize  this 
malady,  and  in  severe  cases  the  resultant  softening  or  hemorrhages  may 
cause  a  true  myelitis. 

Compressed-air  illness  then  is  the  direct  result  not  of  the  increased 
pressure,  but  of  decompression  which  has  been  so  rapid  that  bubbles  of  free 
nitrogen  have  been  liberated  in  the  organism. 

Hence  the  symptoms  never  occur  under  compression,  however  long 
continued,  but  only  as  the  result  of,  and  after,  decompression. 


IQO  SPECIFIC    OCCUPATIONAL   DISEASES 

Such  in  brief  is  the  gas-bubble  theory  which  has  been  indisputably 
established  as  the  correct  and  only  explanation  of  compressed-air  Ulness. 

A  large  proportion  of  all  autopsies  performed  within  24  hours  after 
death  in  the  rapidly  fatal  cases,  whether  among  men  or  in  animal  experi- 
ments, show  visible  bubbles  of  gas  in  the  veins  and  right  heart  and  often 
in  other  tissues. 

Theories. — Other  theories  have  been  advanced  and  tenaciously  held,  but 
they  must  all  fall  to  the  ground  if  for  no  other  reason  than  that  they  do  not 
even  attempt  to  account  for  the  formation  of  a  single  bubble  of  gas. 

1.  The  mechanical  pressure  theory  propounded  by  Pol  and  Wattelle^ 
in  1854,  and  held  by  A.  H.  Smith  and  others,  is  based  upon  false  conceptions 
of  the  effect  of  compression  upon  the  vascular  system,  and  it  fails  to  explain 
the  pathological  findings. 

2.  The  "effects  of  cold  a.nd  fatigue,"  whose  adherents  include  Jaminet,^ 
Tine  and  others,  has  truth  in  it  only  to  the  extent  that  fatigue  and  cold  are 
minor  contributing  factors. 

3.  The  carbon  dioxide  poisoning  theory  of  SnelP  does  not  explain  the  phe- 
nomena of  gas-bubble  formation;  also  its  symptoms  would  occur  during 
exposure  to  pressure,  which  is  never  true  of  compressed-air  illness. 

Furthermore  HilP^  and  Greenwood,  also  Haldane  and  Priestley,  have 
proven  that  the  absolute  partial  pressure  of  CO2  in  the  alveoli  is  regulated 
by  the  rate  of  respiration  and  remains  practically  the  same  (5.6  per  cent.) 
under  compression  even  up  to  +6  atmospheres,  and  consequently  no  more 
is  taken  into  the  blood  under  pressure.  Haldane^  states  that  even  when 
the  air  in  a  caisson  or  diving  helmet  is  so  vitiated  as  to  contain  3  per  cent. 
CO2  pressure  it  will  not  affect  the  man  in  his  work,  although  it  would 
increase  his  respirations;  if  it  contain  more  than  4  per  cent.  CO2  pressure, 
the  resulting  dyspnoea  would  interfere  with  hard  work,  and  only  when  the 
CO2  pressure  is  above  10  per  cent,  will  unconsciousness  from  suffocation 
supervene. 

4.  The  oxygen  poisoning  theory  of  Lorrain  Smith  is  based  on  the  fact 
that  the  breathing  of  very  high  pressures  of  oxygen,  at  from  +7  to  +15 
atmospheres  during  long  exposures,  produces  congestion  and  inflammation 
of  the  lungs. 

As  an  explanation  of  compressed-air  illness,  this  theory  is  of  course  quite 
inadequate. 

ETIOLOGY— PREDISPOSING  FACTORS 

I.  Degree  of  Pressure. — Other  things  being  equal,  the  number  of 
cases  of  illness  increases  directly  with  the  degree  of  pressure. 

Only  a  very  few  minor  cases  of  pain  occurred  at  pressures  up  to  -|-2o 
lb.  One  case  of  transient  hemiplegia  with  aphasia  after  8  hours  at  -I-15  lb. 
was  reported  by  Keays,^  although  the  hemiplegic  case  depends  solely  on 
the  patient's  own  statement  for  he  was  not  seen  by  a  physician. 


COMPRESSED-AIR   ILLNESS  I91 

Haldane  thinks  that  bubbles  will  not  form  even  after  the  most  rapid 
decompression  from  pressures  up  to  +15  lb.,  and  adds  that  symptoms  be- 
gin with  -|-2o  lb.,  are  rare  up  to  +30  lb.,  but  are  serious  in  frequency  above 
+30  lb. 

Bert,^  1878,  was  told  of  one  fatal  case  after  exposure  to  -f-21  lb.,  but 
there  seems  to  be  reason  for  doubting  the  correctness  of  this  report. 

Haldane  never  heard  of  a  fatal  case  below  -{-29  lb. 

At  the  East  River  tunnels  the  lowest  fatal  case  occurred  at  -f  28  lb. 

From  a  wide  practical  experience,  Mr.  Japp"  considers  that  pressures  up 
to  +27  lb.  may  be  regarded  as  free  from  the  risk  of  serious  developments. 

However,  it  is  clear  that  every  additional  pound  above  +30  lb.  carries 
with  it  increasing  risk. 

2.  Length  of  Exposure. — The  degree  of  saturation  of  the  organism,  is 
for  any  given  pressure,  a  matter  of  time.  Were  it  merely  a  question  of  the 
saturation  of  the  blood,  this  might  take  place  in  i  minute,  if  we  premise,  as 
is  probably  true,  that  the  diffusion  of  gases  from  the  alveoli  to  the  blood 
occurs  instantaneously  and  that  the  complete  circulation  of  the  blood  takes 
place  in  i  minute  (Plesch  says  55  seconds  during  Test  but  only  43^^  seconds 
during  hard  work). 

However,  the  saturation  of  the  body  fluids  and  tissues  takes  place  only 
gradually  from  the  blood,  and  those  tissues  which  are  deficient  in  blood 
supply  will  require  more  time  for  saturation. 

Again  we  find  that  certain  tissues  are  better  solvents  for  nitrogen  than 
others.  Thus,  Vernon^-  estimates  that  fat  can  dissolve  five  times  more 
nitrogen  than  the  blood  and  non-fatty  tissues,  by  bulk.  Hence  fat,  which 
makes  up  from  15  to  20  per  cent,  of  the  body  weight  and  is  little  vascular, 
will  saturate  slowly  and  consequently  desaturate  slowly. 

Therefore  as  a  unit  in  saturation  of  the  organism  containing  so  much 
fat,  the  blood  has  an  effective  bulk  of  only  3^5,  although  in  reality  it  is  from 
/4o  to  3^^ 3  of  the  body  weight. 

Attempts  have  been  made  to  calculate  the  rate  of  saturation  of  the 
body  tissues  on  the  basis  that  3^5  saturation  occurs  in  i  minute  and  3'^5 
of  2^^5  in  the  second  minute,  etc.  Thus  Haldane^  and  Boycott  estimate 
that  22  per  cent,  saturation  will  occur  in  5  minutes,  50  per  cent,  saturation 
in  about  25  minutes  and  almost  complete  saturation  in  90  minutes,  but 
the  slowest  parts  might  require  5-9  hours  for  complete  saturation. 

Turning  from  the  theoretical  consideration  of  this  question  to  the  results 
of  practical  work  in  compressed  air,  Keays^  found  that  among  2719  men 
exposed  to  +31  lb.  pressure  for  i3^^  hours  on  a  preliminary  test  and  there- 
fore not  working,  only  three  cases  (0.18  per  cent.)  of  illness  developed, 
whereas  among  2000  men  working  for  13^^  hours  at  -I-32  lb.  there  were  seven 
cases  or  0.35  per  cent.  (In  this  instance  the  length  of  exposure  was  the 
same,  but  the  effect  of  work  in  hastening  saturation  is  illustrated.)  After 
two  3-hour  shifts  at  31.7  lb.  1.46  per  cent,  developed  symptoms,  ,in  3360 


192  SPECIFIC    OCCUPATIONAL    DISEASES 

man  shifts,  whereas  in  23,760  man  shifts  (two  shifts  of  4  hours  each)  there 
were  216  cases  or  only  0.90  per  cent. 

From  these  statistics  Keays  concludes  that  saturation  is  not  complete 
after  i}<2  hours,  although  it  is  more  nearly  so  if  the  men  are  working  than  if 
they  are  resting;  that  after  3  hours'  work  saturation  is  practically  complete 
and  longer  exposures,  e.g.,  of  4  hours,  did  not  increase  the  percentage  of  cases 
of  illness.  In  fact  the  percentage  after  the  4-hour  shifts  was  smaller  than 
after  the  3-hour  shifts,  which  apparent  discrepancy  I  would  attribute  to  the 
fact  that  the  longer  interval  between  shifts  (4  hours  for  the  4-hour  shifts  and 
3  hours  for  the  3-hour  shifts)  enabled  the  4-hour  men  to  become  more  com- 
pletely desaturated  as  well  as  rested  before  going  down  to  their  second  shift. 

No  less  an  authority  in  practical  engineering  than  Mr.  E.  W.  Moir^- 
states  that  he  "is  confident  that  a  limitation  of  the  exposure  to  even  3  hours 
distinctly  diminishes  the  risk  of  bends  as  compared  with  6  or  8  hours' 
exposure. 

However,  we  may  conclude  from  the  statistics  cited  above  that  for 
practical  purposes  saturation  occurs  after  3  hours'  work  under  pressure,  for 
the  average  man. 

3.  The  Personal  Equation. — A.  Efficiency  of  ihe  circulation  would  epito- 
mize the  qualifications  for  good  air  workers,  and  any  condition  which 
tends  to  lower  the  tone  and  elasticity  of  the  blood-vessels  or  to  cause  passive 
congestion  will  in  so  far  retard  desaturation  and  predispose  to  the  collection 
and  coalescence  of  gas  bubbles  in  the  circulation.  Hence  we  note  as  predis- 
posing factors  debilitation  from  disease  or  malnutrition,  from  alcoholic  and 
other  excesses;  constipation;  fatigue;  the  effects  of  cold  and  the  lack  of 
exercise  during  decompression  and  afterward. 

B.  Organic  diseases,  especially  arteriosclerosis,  heart  lesions,  respiratory 
diseases,  interfere  with  rapid  desaturation.  Anaemia,  oedema,  status  lym- 
phaticus  have  all  been  reported  in  some  of  the  fatal  cases,  and  naturally  such 
diseases  should  prohibit  work  in  compressed  air. 

C.  Age. — Men  from  18  to  30  years  of  age  are  the  most  desirable  for  pres- 
sure work,  because  of  their  efficient  vascular  and  general  condition.  Beyond 
30  years  the  risk  of  serious  illness  increases,  and  with  few  exceptions  men 
over  40  years  of  age  should  be  excluded. 

D.  Fat  men  are  notoriously  ill-fitted  for  work  in  high  pressures,  a  practical 
observation  which  is  fully  explained  by  the  slow  desaturation  of  fat,  and  sub- 
stantiated by  the  animal  experiments  of  Boycott  and  Damant. 

E.  Fatigue  may  be  conceived  as  playing  a  role  in  the  causation,  by  im- 
pairing the  efficiency  of  the  circulation;  indeed,  Keays^  holds  it  responsible 
for  the  fact  that  for  the  same  men  at  the  same  pressures  there  was  an  in- 
crease of  cases  of  illness  after  the  second  3-hour  shift  (0.72  per  cent.)  when 
compared  with  the  first  3-hour  shift  (0.35  per  cent.).  However,  I  would  note 
another  possible  factor  here,  namely,  the  incomplete  desaturation  during  the 
3-hour  (often  23^^-hour)  interval  between  shifts. 


COMPRESSED-AIR   ILLNESS 


193 


4.  Atmospheric  Conditions. — Above  ground  have  been  thought  by  some 
men  to  affect  the  incidence  of  illness,  but  we  were  not  able  to  establish  any 
such  connection  at  the  East  River  tunnels,  where  we  kept  a  daily  record 
of  the  temperature,  barometer  readings,  humidity  and  direction  of  the  wind. 

The  humidity  in  the  tunnels  was  always  nearly  at  saturation,  nev^er  under 
90  per  cent.  (McWhorter).^" 

5.  Noxious  Gases. — -The  possible  presence  of  injurious  quantities  of 
carbon  dioxide,  of  carbon  monoxide,  of  methane,  of  sulphuretted  hydrogen, 
or  of  nitric  oxide  in  a  tunnel  or  caisson  might  call  for  remedy  in  the  way  of 
better  ventilation;  but  even  supposing  their  presence  in  excess,  either  from 
the  compressors,  or  from  blasting,  or  from  any  cause  whatsoever,  the  result- 
ant symptoms  would  be  due  to  the  exciting  cause  and  would  develop  while 
the  men  were  under  pressure,  and  although  conceivably  they  might  be  pre- 
disposing factors,  they  are  never  essential  factors  in  the  etiology  of  com- 
pressed-air illness. 

Carbon  Dioxide. — At  the  East  River  tunnels,  McWhorter's  daily  analyses 
of  the  tunnel  air  showed  such  excellent  ventilation  that  the  maximum  carbon 
dioxide  reading  was  o.i  per  cent,  (the  equivalent  of  0.3  per  cent,  at  3  atmos- 
pheresj;  the  minimum  was  0.045  per  cent.,  and  the  carbon  dioxide  variations 
had  no  efiFect  upon  the  percentage  of  illness. 

Carbon  Monoxide. — Haldane  states  "that  anything  over  0.15  per  cent,  of 
carbon  monoxide  must  be  regarded  as  distinctly  dangerous,  and  probably 
anything  over  0.03  per  cent,  would  in  time  produce  symptoms  distinctly  felt 
on  exertion." 

Immediately  after  blasting  in  our  tunnels,  samples  of  air  from  the  headings 
showed  a  maximum  of  0.045  P^r  cent.  CO,  but  this  was  rapidly  removed  by 
ventilation;  further,  McWhorter  says  that  although  some  of  the  men  com- 
plained of  headache  after  the  blasting,  he  does  not  regard  this  as  a  symptom 
of  carbon  monoxide  poisoning. 

Methane  was  never  found  and  nitric  oxide  and  sulphuretted  hydrogen 
only  occasionally  and  in  most  minute  quantities. 

Exciting  Cause. — The  immediate  and  exciting  cause  of  compressed-air 
illness  is  too  rapid  decompression.     (See  Treatment,  for  details.) 

Immunity. — This  is  purely  a  relative  matter  and  probably  no  absolute 
immunity  exists,  but  the  best-adapted  men  may  escape  symptoms,  at  least 
for  a  long  time,  and  rarely  one  encounters  old  and  experienced  workers  who 
have  never  had  a  twinge  of  the  "bends." 

Pathology .^ — Bubbles  of  gas,  set  free  in  the  tissues  and  fluids  of  the  body, 
give  rise  to  the  pathological  lesions  found  at  autopsy,  as  well  as  to  the  tran- 
sient symptoms  which  characterize  the  non-fatal  cases. 

The  pathognomonic  and  most  striking  lesion   is   the  presence  of  gas 

bubbles  (gas  emboh)  in  the  veins  of  the  systemic  and  portal  system,  in  the 

right  heart,  and  in  the  pulmonary  and  coronary  vessels.     These  bubbles  are 

found  so  constantly  in  animal  experimentation  and  in  the  majority  of  autop- 

13 


194 


SPECIFIC   OCCUPATIONAL   DISEASES 


sies  upon  men  in  the  rapidly  fatal  cases  (provided  the  autopsy  be  performed 
within  24  hours  after  death)  that  they  constitute  the  basis  of  our  under- 
standing of  this  disease. 

Death  in  many  cases  is  the  result  of  distention  of  the  right  heart  with 
gas,  or  of  pulmonary  air  embolism. 

Nature  of  the  Gas. — Analyses  of  the  gas  drawn  from  the  right  side  of  the 
heart  of  animals  killed  after  rapid  decompression  from  high  pressures  are 
represented  by  the  following: 


Nitrogen,  |    Oxygen, 
per  cent.    1    per  cent. 


Carbon 
dioxide, 
per  cent. 


Paul  Bert,2  1878: 

1.  Dog 

2.  Cat 

Von  Schrotter:* 

I-  Dog 

2.  Dog 

McWhorterio  and  Erdman:'^ 
I.  Tunnel  worker* 


84.1 

79.98 
80.37 

80.0 


2.0 
None 

15-31 
7.18 

None 


IS-2 

iS-9 

4-71 
12.45 


How  then  are  we  to  explain  these  analyses  if  we  maintain  that  nitrogen 
is  the  sole  factor  in  supersaturation?  Haldane  states  that  the  amount  of 
oxygen  taken  by  the  blood  under  conditions  of  pressure  adds  but  little  to 
the  total  oxygen  of  arterial  blood  and  in  any  event  readily  combines  with 
the  tissues,  and  for  the  reasons  stated  under  "the  carbon  dioxide  theory" 
we  have  seen  that  no  more  than  the  normal  amount  of  COo  is  taken  by  the 
blood. 

Why  do  not  the  analyses  reveal  nitrogen  alone?  HilP-  explains  this  by 
saying  that  "when  nitrogen  is  set  free  as  bubbles,  these  act  as  a  vacuum 
for  CO2  and  oxygen,  and  some  of  these  gases  are  set  free  out  of  chemical 
combination  with  the  blood;  and  as  the  oxygen  is  mostly  used  up  by  the 
tissues  of  the  dying  animal,  we  find  the  chief  gas,  besides  nitrogen,  is  CO2." 
(Witness  the  analysis  from  the  human  heart,  above  recorded.) 

The  nervous  system  may  or  may  not  show  lesions  at  autopsy,  although 
irritation  of  the  peripheral  nerves  or  spinal  cord,  by  bubbles,  gives  rise  to 
nearly  90  per  cent,  of  the  symptoms  of  the  disease, 

*  So  far  as  I  can  find,  this  latter  is  the  only  recorded  analysis  of  gas  from  the  human 
heart  after  death  from  compressed-air  illness. 

The  autopsy  was  performed,  about  14  hours  after  death,  upon  a  tunnel  worker  who 
died  Nov.  19,  1907,  i  hour  after  decompression,  having  been  found  in  a  state  of  collapse 
and  unconsciousness  near  the  works.  The  man  had  worked  8  hours  in  a  pressure  of 
+30  lb.  and  had  left  the  tunnel  by  a  17-minute  uniform  decompression.  The  right 
heart  was  found  to  be  ballooned  with  gas  and  some  of  this  (3.1  cc.)  was  aspirated  into 
a  specially  devised  collector  after  flooding  the  thorax  with  water  and  excluding  all  air 
from  the  collector.     The  analysis  was  made  by  Dr.  Metzger  of  Columbia  University. 


COMPRESSED-AIR   ILLNESS  I95 

Fat  acts  as  a  reservoir  for  nitrogen,  and  Vernon  estimates  that  the  spinal 
cord  and  the  peripheral  nerves  contain  20  per  cent.  fat. 

Especially  in  cases  of  paralysis,  autopsy  may  show  capillary  hemorrhages, 
or  areas  of  softening  due  to  embolism,  in  the  spinal  cord,  or  even  laceration 
of  nerve  cells  by  the  expanding  bubbles.  In  persistent  paraplegias,  a  true 
"caisson  myelitis"  is  found. 

The  lower  dorsal  and  the  upper  lumbar  regions  are  most  often  affected 
because  of  their  meager  blood  supply  in  comparison  with  the  functionally 
more  active  segments.  Gray  matter  has  a  richer  blood  supply  than  white 
matter  and  so  more  often  escapes. 

Gas  bubbles  or  resultant  capillary  hemorrhages  and  tissue  changes 
may  be  found  in  the  liver,  spleen  and  other  organs;  indeed  bubbles  may  occur 
in  nearly  all  the  body  tissues  and  more  detailed  mention  will  be  found  in 
the  symptomatology  given  below. 

Phenomena  of  Compression.^^ — Certain  interesting  physical  and  mechan- 
ical phenomena  are  noted  during  the  process  of  compression: 

1.  The  rising  pressure  forces  inward  the  ear-drum  membrane,  causing 
discomfort,  acute  pain,  or  even  rupturing  this  structure,  unless  the  pressure 
be  equalized  by  admitting  air  through  the  Eustachian  tube,  by  Valsalva's 
method  or  an  equivalent,  e.g.,  swallowing.  This  pressure  on  the  ear-drum 
membrane  is  most  marked  with  the  first  few  pounds  and  so  it  is  possible  to 
rupture  the  membrane  with  -I-5  to  -f-io  lb.  pressure,  but  this  can"not  be 
considered  a  symptom  of  compressed-air  illness. 

2.  Shght  rise  in  body  temperature  and  sweating  occur,  due  to  the  heat 
generated  by  the  compression  of  the  air. 

3.  The  denser  air  offers  a  slight  resistance  to  expiration  and  phonation. 
Whispering  becomes  impossible,  and  the  lessened  amplitude  of  vibration 
renders  whistling  difl&cult  or  impossible,  and  in  such  an  attempt  the  non- 
vibrating  lips  give  a  sensation  of  sHght  numbness. 

4.  The  voice  loses  its  natural  quality  and  sounds  intensely  nasal. 

5.  A  sense  of  exhilaration  and  an  ease  of  movement  are  experienced,  and 
it  is  claimed  that  compressed-air  work  increases  the  appetite. 

Other  phenomena  of  compression  have  been  reported,  but  are  now 
generally  discredited;  thus: 

Pallor  of  the  skin  and  mucous  membranes  does  not  occur  unless  it  be 
from  nervousness  on  the  part  of  the  man  entering  compressed  air  for  the  first 
time. 

There  is  no  lessening  of  the  volume  of  the  pulse;  no  constant  alteration 
in  the  blood  pressure;  no  constant  change  in  the  rate  either  of  the  pulse  or 
respirations. 

The  superficial  veins  do  not  collapse;  the  capillary  circulation  in  a  frog's 
foot  continues  unchanged  (Hill  and  others). 

There  is  no  gross  change  in  the  urinary  or  sweat  secretions.  Hearing 
is  not  affected. 


196  SPECIFIC    OCCUPATIONAL    DISEASES 

Phenomena  of  decompression  include  chilling  of  the  body,  due  to  the 
falling  temperature  in  the  air  lock,  and  one  may  at  times  note  a  crackling 
sound  in  the  ears  as  the  air  escapes  through  the  Eustachian  tubes.  With 
rapid  decompression  the  moisture  in  the  atmosphere  condenses  and  the 
lock  fills  with  a  dense  fog. 

Symptoms.— The  symptoms  of  compressed-air  illness  occur  only  as  a 
result  of,  and  after  completion  of,  decompression;  and  no  symptoms  ever 
develop  while  a  man  remains  in  the  compressed  air,  no  matter  what  the  degree 
of  pressure  nor  the  length  of  exposure. 

A.  Onset. — The  time  of  onset  is  from  within  a  few  minutes  up  to  a  few 
hours  after  decompression.  At  the  East  River  tunnels  about  50  per  cent,  of 
the  3692  cases  developed  within  30  minutes,  and  95  per  cent,  within  3  hours; 
however,  i  per  cent,  were  delayed  over  6  hours  and  of  these,  four  isolated  and 
somewhat  doubtful  cases  were  said  to  have  occurred  between  15  and  23  hours 
after  decompression  (Keays). 

Bert  says  that  the  bubbles  do  not  form  all  at  once  but  continue  to  form 
for  some  time  after  decompression. 

The  onset  of 'symptoms  is  often  dramatic  in  its  suddenness.  A  man  in 
all  the  vigor  of  health  and  strength  descends  to  his  daily  task  in  the  river 
tunnel;  enters  the  compressed  air;  works  his  regular  shift  of  3  or  4  hours; 
comes  out  through  the  air  lock  by  the  ordinary  method  of  decompression; 
ascends  to  the  street  and  starts  for  home,  feeling  perfectly  well. 

Fifteen  minutes  later,  without  the  slightest  warning,  he  is  attacked  with 
intense  boring  pains  in  his  legs  and  abdomen,  or  he  staggers  and  falls  help- 
less to  the  ground,  paralyzed  from  his  waist  down.  Fortunate  he  is  if  efficient 
treatment  be  near  at  hand,  and  by  recompression  in  the  medical  air  lock,  his 
pains  vanish,  his  paralysis  disappears,  and  on  the  morrow  he  returns  to  his 
work  as  usual. 

B.  Chief  Symptoms  in  Order  of  Frequency: 

1.  Pains  in  the  extremities  or  abdomen  occur  in  ^?>  per  cent,  of  all  cases. 

2.  Vertigo,  in  about  5  per  cent. 

3.  Cerebrospinal  cases,  in  2.16  per  cent. 

4.  Dyspnoea,  or  "chokes,"  in  over  1.5  per  cent. 

5.  Prostration  of  moderate  degree,  with  pains,  in  1.25  per  cent. 

6.  Collapse  with  unconsciousness,  in  0.46  per  cent. 

C.  Classification  of  Acute  Symptoms. — The  symptoms  of  compressed-air 
illness  will  vary  with  the  anatomical  part  affected,  with  the  amount  of  gas 
set  free,  and  with  the  consequent  degree  of  disturbance  of  function;  accord- 
ingly we  wiU  group  the  symptoms  with  reference  to  the  structures  afYected. 

I.  Nervous  System.- — (a)  Peripheral  Nerves. — Pain  is  by  far  the  com- 
monest symptom,  occurring  in  over  88  per  cent,  of  all  cases,  either  as  the  only 
symptom  or  associated  with  others.  Its  most  frequent  (70  per  cent.)  site 
is  in  the  lower  extremities  in  the  region  of  the  knees,  forcing  the  victim  into 
an  attitude  which  gives  rise  to  the  popular  term  "bends,"  or  "courbatures." 


COMPRESSED-AIR    ILLNESS  I97 

Next  in  frequency  are  pains  in  the  upper  extremities,  about  the  elbows  and 
shoulders  in  30  per  cent.  Pains  in  the  abdomen  occurred  in  about  5  per  cent, 
of  the  cases,  but  were  of  greater  significance  than  were  pains  in  the  extremities 
in  that  they  more  often  preceded  or  accompanied  cases  of  severe  prostration 
or  paralysis. 

Pain  occurring  in  the  extremities  or  abdomen  in  over  88  per  cent,  of  all 
cases,  without  other  evidence  of  spinal-cord  irritation,  except  in  a  little  over 
2  per  cent.,  must  admittedly  be  due  to  peripheral  irritation  of  nerves  and 
nerve  terminals  by  bubbles  of  gas  in  the  nerve  sheath,  in  fascial  tissues,  be- 
neath the  periosteum  or  in  bone  marrow,  etc. 

Numbness,  anaesthesia,  and  paraesthesia  a're  doubtless  capable  of  the  same 
explanation. 

One  form  of  paraesthesia,  called  by  the  workmen  "itch,"  is  quite  common, 
and  distressing  while  it  lasts,  but  is  never  of  serious  import.  This  may  be  ex- 
plained, as  Hill  does,  as  due  to  bubbles  in  the  subcutaneous  areolar  tissue, 
but  in  my  experience  it  is  no  more  common  in  fat  men  than  in  thin  men;^^  it 
occurs  especially  when  sweating  has  been  less  free,  and  it  is  usually  at  once 
relieved  by  a  hot  bath  or  sweating,  all  of  which  make  it  more  probable  that 
it  is  caused  by  expanding  bubbles  in  the  sweat  glands. 

The  "itch"  or  '"puces"  has  been  attributed  to  irritation  of  the  posterior 
nerve  roots  by  bubbles  in  the  spinal  fluid. 

(b)  Central  Nervous  System. — Brain:  unconsciousness,  stupor,  and  col- 
lapse may  be  due  to  cerebral  gas  embolism  or  the  resulting  oedema,  or  are 
secondary  to  circulatory  failure  due  to  coronary  or  pulmonary  embolism. 

Cerebral  gas  embolism  may  also  cause  temporary  aphasia,  incoherence 
of  speech,  ataxia,  vomiting,  vertigo,  headache;  or  such  signs  as  hemiplegia, 
monoplegia,  convulsions,  nystagmus,  and  tongue  deviations,  depending 
upon  what  area  is  affected. 

Actual  tearing  of  nerve  tissue  and  hemorrhage  may  arise  from  the 
expansion  of  bubbles  of  gas,  resulting  in  organic  lesions. 

Vertigo,  or,  in  the  parlance  of  the  workers,  "staggers,"  was  met  with  in 
over  5  per  cent.,  and  is  explainable  by  the  formation  of  bubbles  in  the  laby- 
rinth of  the  internal  ear,  or  when  accompanied  by  nausea  and  vomiting  it 
may  be  due  to  cerebellar  gas  embolism. 

Spinal  Cord :  Affections  of  the  spinal  cord  include  paraplegia,  monoplegia, 
loss  of  bladder  and  rectal  control,  partial  paralyses,  spasticity,  exaggerated, 
diminished,  or  absent  reflexes,  anaesthesia,  anaesthesia  dolorosa,  etc.;  and  with 
hemorrhage  into  the  cord  the  symptoms  may  become  permanent  and  a  true 
myelitis  may  develop. 

Frequently,  however,  there  is  only  a  temporary  weakness  and  numbness 
of  the  legs,  with  or  without  retention  of  urine. 

2.  Special  Senses. — (a)  Eye. — Transient  blindness,  diplopia  and  nys- 
tagmus may  occur. 

(b)  Ear. — Perforation  of  the  membrani  tympani  due  to  compression  is 


1 98  SPECIFIC    OCCUPATIONAL  DISEASES 

not  properly  a  symptom  of  the  illness.     Deafness  and  vertigo  or  Meniere's 
disease  may  result  from  the  formation  of  bubbles  in  the  labyrinth. 

3.  Vascular  System. — The  phenomena  of  gas  emboli  in  the  blood-vessels 
has  been  described,  and  undoubtedly  the  cases  of  extreme  prostration  and 
collapse  and  many  of  the  fatalities  are  due  to  the  collection  of  gas  in  the  right 
side  of  the  heart. 

A  bluish  "mottling"  of  the  surface  of  the  chest  or  abdomen,  encountered 
in  some  of  the  more  severe  cases,  is  due  to  embolism  of  the  superficial  veins. 

Lymphatic  obstruction  by  gas  emboli  explains  the  several  cases  of  local- 
ized oedema  which  I  have  observed. 

4.  Respiratory  System. — A  form  of  dyspnoea,  called  "chokes,"  of  a  type 
resembling  an  asthmatic  attack,  may  well  be  due  to  multiple  small  emboli  in 
the  pulmonary  vessels;  for  were  it  of  central  nervous  origin,  it  would  prob- 
ably be  attended  by  other  serious  nervous  symptoms,  which  is  not  the 
case. 

In  certain  fatal  cases  there  has  been  found  oedema  of  the  lungs,  and  at 
times  an  interstitial  emphysema. 

5.  Gastrointestinal  symptoms  further  than  the  epigastric  pains,  the 
nausea  and  vomiting,  above  described,  are  not  encountered. 

6.  Internal  organs,  such  as  the  liver,  spleen,  kidneys,  do  not  give  any 
acute  signs,  although  at  autopsy  they  may  be  found  affected. 

7.  The  sexual  apparatus  is  affected  only  as  a  result  of  spinal-cord  injury, 
which  may  give  rise  to  priapism,  etc. 

8.  The  Bones,  Joints  and  Periosteum. — ^In  one  case  necrosis  of  the  femur 
resulted  apparently  from  thrombosis  of  the  medullary  artery.  The  deep- 
seated  pains  so  frequently  referred  to  the  long  bones  of  the  extremities  and 
to  the  joints  may  be  due  either  to  collections  of  expanding  bubbles  under 
the  fascial  planes  or  under  the  periosteum;  or,  as  Hill  suggests,  in  the  yellow 
marrow,  which  structure  is  rich  in  fat  and  deficient  in  circulation. 

9.  The  Skin  and  Subcutaneous  Tissues. — The  symptoms  of  "itch"  and 
the  "mottling"  of  the  skin  have  been  described  above.  Subcutaneous  em- 
physema, without  trauma,  is  met  with  in  a  few  cases  during  life,  and  fre- 
quently-in  autopsies,  especially  along  the  course  of  the  large  vein  of  the  ex- 
tremities. Its  presence  as  an  accompaniment  of  contusions  and  punctured 
wounds  I  have  several  times  demonstrated,  and  it  is  doubtless  due  to  the 
setting  free  of  gas  from  the  extravasated  blood;  for  it  is  hardly  likely  that 
such  an  amount  of  compressed  air  could  enter  through  the  puncture. 

10.  Localized  collections  of  gas,  aside  from  the  small  emboli  scattered 
through  the  body,  include  the  large  collections  found  in  the  right  side  of 
the  heart  at  autopsy  (case  cited  above).  At  one  autopsy  which  I  witnessed 
there  was  a  collection  of  about  5  cc.  of  gas  beneath^  the  mucosa  of  the  jejunum. 
In  two  other  cases  I  succeeded  in  aspirating  about  i  cc.  of  gas  from  beneath' 
the  periosteum  of  the  tibia;  its  presence  was  evidenced  by  a  soft  cushion- 
like swelling  in  this  area. 


COMPRESSED-AIR   ILLNESS  199 

II.  Miscellany. — In  general,  the  wounds  bleed  as  freely  and  heal  as 
readily  in  the  compressed  air  as  in  the  normal  atmosphere. 

Complications. — Perforation  of  the  membrani  tympani  may  be  called  a 
complication;  also  infections  of  the  middle  ear  and  of  the  sinuses  which  com- 
municate with  the  nose  are  favored  by  the  efforts  of  the  men  to  force  open 
the  Eustachian  tubes,  and  these  factors  account  for  the  infrequent  cases  of 
epistaxis  in  caisson  or  tunnel  work. 

In  diving,  however,  bursting  of  the  air  tube  has  a  cupping  effect  and  may 
cause  epistaxis,  ecchymoses  and  rupture  of  the  membrana  tympani  in  an 
outward  direction. 

Cystitis,  pyelonephritis,  myelitis  and  meningitis  may  be  later  results 
of  spinal-cord  injury. 

Symptoms:  Chronic. — (a)  Myelitis. — At  the  East  River  tunnels,  ex- 
clusive of  the  fatal  cases  which  died  within  8  days,  there  were  10  cases  of 
permanent  paralysis,  or  0.3  per  cent,  of  the  total  cases.  Of  the  10,  four 
died  within  5  months  from  complications,  three  were  lost  track  of,  and  the 
remaining  three,  at  last  reports  were  still  afflicted  with  spastic  paraplegia. 

(6)  Permanent  Ear  Troubles. — I  knew  of  but  three  cases  (in  the  3692), 
of  ruptured  membrana  tympani  and  with  persistent  impairment  of  hear- 
ing; one  of  these  developed  an  obstinate  otitis  media  purulenta. 

As  has  been  said  above,  these  cases  are  perhaps  complications  of  work  in 
compressed  air  but  are  not  symptoms  of  compressed-air  illness;  rather  were 
they  accidents  of  compression. 

However,  cases  of  labyrinthine  deafness  are  reported  as  setting  in  after 
decompression,  and  due  to  bubbles  in  the  labyrinth;  such  cases  of  which  I  saw 
no  permanent  ones,  would  be  properly  classed  as  symptoms  of  this  disease. 

Meniere's  symptom-complex  is  of  similar  origin  and  I  knew  of  one  per- 
sistent case. 

That  many  and  vague  symptoms  in  after  life  are  attributed  to  the 
effects  of  compressed-air  illness,  which  have,  however,  no  actual  connection 
therewith,  is  a  fact  to  which  the  testimony  submitted  in  certain  damage  suits 
bears  eloquent  testimony. 

Bassoe^^  examined  161  men  at  a  period  of  months  or  in  some  cases, 
years  after  they  had  worked  in  compressed  air,  and  he  reports  16  cases  of 
demonstrable  permanent  injury,  or  10  per  cent.,  and  ear  troubles  in  over 
60  per  cent. 

His  grouping  is  as  follows: 
Class  I.  Caisson  myehtis. 

(fl)  Trophic  osteo-arthropathy  due  to  cord  lesion  (cases,  three). 
{b)  Very  limited  persistent  cord  lesions  (cases,  two), 
(c)    Caisson  myelitis  more  or  less  extensive  (cases,  three). 
Class  2.     Permanent  joint  disease  (arthritis  deformans)  cases,  seven. 
Class  3.     Ear  affections.   67  men  complained  of  impaired  hearing. 

T,T,  complained  of  dizziness. 


200 


SPECIFIC    OCCUPATIONAL    DISEASES 


Certainly  from  our  experience  at  the  East  River  tunnels  in  the  3692 
cases  we  consider  Bassoe's  statistics  quite  amazing.  In  a  number  of  his 
cases,  we  feel  that  the  very  essential  relation  of  cause  to  effect  is  not  suf- 
ficiently well  established. 

In  a  word  we  may  state  that  as  a  result  of  Keays'  analysis  of  the  East 
River  tunnel  cases,  the  total  of  permanent  injury  cases  does  not  exceed  i.o 
per  cent,  even  when  we  include  all  fatal  cases  and  all  persistent  paralyses  and 
permanent  ear  affections. 

Mortality. — Except  for  the  doubtful  case  related  by  Bert  of  a  man  who 
died  after  exposure  to  -f-  21.1  lb.  (?),  I  can  find  no  record  of  fatalities  occur- 
ring under  +28  lb. 

An  idea  of  the  great  variation  in  mortality  at  different  works  may  be 
obtained  from  the  following  statistics: 

(a)  Mortality  in  relation  to  pressure  and  cases  of  illness.  We  believe 
that  with  modern  methods  of  decompression  and  treatment  the  mortality 
should  never  amount  to  even  0.5  per  cent,  of  the  cases  of  illness. 


.Max.  pressure, 
lb. 


Cases 


Deaths 


Percentage 


1839,  Douchy  mines 1     +37-5 

1870,  St.  Louis  bridge +50.0 

+34-0 
+35 -o 
+32.5 
+37-5 


1873,  Brooklyn  bridge 

1885,  Hudson  tunnel 

1890,  Danube  bridge 

1895,  Danube  bridge 

1906,  Amsterdam -f-30.0 

1909,  East  River  tunnel +32-4 


63 

2 

3-2 

129 

14 

10.8 

no 

3 

2.72 

50  workers 

9 

1 8.0  plus 

154 

4 

2.6 

320 

2 

0.625 

228 

none 

20 

3692 

0.54 

In  comparing  the  above  figures,  note  that  only  the  maximum  pressure  emplo3'ed  at  any 
period  of  construction  is  given,  except  in  the  case  of  the  East  River  tunnels  where  the 
average  for  the  whole  work  was  +32  lb.  and  the  maximum  was  +42  lb. 

At  Amsterdam  where  there  were  no  deaths  it  will  be  seen  that  the  pressure  at  no  time 
exceeded  +30  lb.;  and  as  has  been  stated  it  is  every  additional  pound  above  +30  which 
especially  enhances  the  danger  of  serious  cases. 

(b)  Mortality  according  to  number  of  workers  employed: 


Hudson  tunnel 

East  River  tunnel. 


(c)  Mortality,  according  to  decompressions: 


Admiralty  Com.  Report. 
East  River  tunnels 


Men 

Deaths 

Percentage 

50 

9 

18.0 

10,000 

20 

0.2 

pressions: 

Decompressions 

Deaths 

Percentage 

60,000 

4 

0.0066 

557,000 

20 

0.0035 

Types  of  Fatal  Cases. — The  20  fatal  cases  at  the  East  River  tunnels 
were  either  rapidly  fatal  (within  a  few  hours  or  a  few  days) ,  or  delayed^for 
weeks  or  months. 


COMPRESSED-AIR    ILLNESS  20I 

A.  Rapidly  fatal  cases. 

1.  Pains  accompanied  by  marked  prostration,      6  cases. 

2.  Collapse  and  early  unconsciousness,  9  cases. 

3.  Paraplegia,  with  coma  later,  i  case. 

B .  Delayed  Deaths. — These  were  due  to  complications  in  cases  of  myelitis ; 
e.g.,  cystitis,  pyelitis,  bed-sores,  etc.;  in  one  case  death  occurred  on  the  tenth 
day  from  an  ascending  paralysis.  Only  one  of  the  twenty  lived  as  long  as 
5  months. 

Diagnosis. — The  diagnosis  is  made  from  the  history  which  will  consist  in 
the  onset  of  symptoms  within  from  a  few  minutes  to  a  few  hours  after  de- 
compression from  compressed  air.  Without  such  a  history,  the  air  worker 
who  falls  unconscious  or  hemiplegic  upon  the  street,  may  well  baffle  the  best 
diagnostician. 

Prognosis. — Simple  pains,  or  ''bends,"  limited  to  the  extremities  are  rarely 
of  serious  import,  and  occurred  in  88  per  cent,  of  all  cases;  they  are  often 
transient  and  shifting  and  usually  yield  at  once  to  recompression.  Pain 
in  the  abdomen  often  precedes  severe  symptoms. 

The  Admiralty^^  Committee  considers  "bends"  to  be  the  sign  of  satura- 
tion of  very  slow  parts,  which  will  be  slow  to  desaturate,  and  therefore  the 
"bends"  are  most  difflcult  of  entire  elimination  by  any  practical  method  of 
decompression;  further  they  occur  independent  of  the  amount  of  fat  in  the 
subject. 

The  more  severe  symptoms  of  dyspnoea,  motthng,  paralyses,  collapse 
and  unconsciousness,  bespeak  inadequate  de-saturation  of  the  quick  parts, 
and  indicate  much  gas  in  the  blood  and  are  accordingly  of  serious  portent. 

Of  the  34  cases  of  paralysis,  23  recovered  (19  of  these  after  one  re- 
compression). 

Of  17  cases  with  early  lapse  into  unconsciousness,  9  were  fatal  and 
represented  45  per  cent,  of  the  total  mortality. 

To  recapitulate  we  may  state  that  many  cases  of  the  "bends"  will 
subside  in  at  most  a  few  days  even  without  recompression.  About  90 
per  cent,  of  all  cases  were  entirely  relieved  by  treatment,  and  99  per  cent, 
were  in  large  part  relieved  by  recompression. 

The  fatal  cases  and  the  permanent  injuries,  taken  together,  amounted 
to  only  I  per  cent,  of  the  3692  cases. 

Treatment 
I.  Prophylactic. 

A.  Choice  of  men. 

B.  Hygiene  of  the  workers. 

C.  Amount  of  pressure. 

D.  Length  of  exposure. 

E.  Method  and  duration  of  decompression. 


202  SPECIFIC   OCCUPATIONAL  DISEASES 

2.  Active  Treatment. 

(c)  Recompression. 

(b)    Palliative  and  adjuvant  measures. 
I.  Prophylactic. 

A.  Selection  of  men  of  suitable  age  and  circulatory  efficiency,  with  the 
exclusion  of  the  fat,  the  anaemic,  and  the  arteriosclerotic,  are  important 
factors  which  have  been  already  discussed.  Hill  says  "skinny  men  are  the 
best  for  high  pressure  work." 

B.  The  hygiene  of  the  workers  demands  attention.  Plenty  of  sleep, 
a  nutritious  diet  (with  but  little  of  fatty  food),  avoidance  of  alcoholic  and 
other  excesses,  exercise  of  the  limbs  (during  and  after  decompression)  and 
regularity  of  the  bowels,  are  important  rules  for  air  workers. 

The  locks  during  decompression  become  very  cold  and  either  they  should 
be  heated  or  the  men  should  be  protected  by  extra  clothing.  Hot  coffee 
and  warm  dressing-rooms  and  baths  should  be  furnished  the  men  after  leav- 
ing the  compressed  air. 

C.  The  amount  of  pressure  is  of  course  the  greatest  etiological  factor, 
but  at  the  same  time  it  is  the  one  factor  which  is  absolutely  beyond  control 
if  work  is  to  be  accomplished  at  great  depths. 

Greenwood^^  safely  underwent  a  pressure  of  +92  lb.  in  an  experimental 
chamber,  and  Haldane  reports  that  a  diver  descended  to  pressure  of  +92.4 
lb.  without  accident,  but  probably  +50  lb.  must  still  be  considered  prac- 
tically a  maximum  pressure  for  construction  work  although  Hill  believes  that 
for  short  exposures  of  picked  workers,  -f  60  lb.  is  feasible. 

D.  Length  of  exposure  means,  practically,  length  of  shifts. 

The  question  of  the  proper  limits  for  working  shifts  at  different  pressures 
is  still  open  to  debate,  and  calls  for  unbiased  consideration,  for  one  must 
avoid,  on  the  one  hand,  imposing  unfair  risk  of  injury,  on  the  working  man, 
by  too  long  exposures;  on  the  other  hand,  it  is  unfair  to  the  contractors  to 
stipulate  unnecessarily  short  working  periods. 

It  is  well  established  that  very  brief  exposures,  e.g.,  up  to  ^^  hour  are 
attended  with  a  minimum  of  risk;  hence  lock- tenders,  engineers,  inspectors, 
and  time-keepers,  by  reason  of  their  usually  brief  exposures  are  much  less 
apt  to  develop  symptoms  than  are  the  hard-working  men  on  a  regular  shift, 
but  of  course  similar  conditions  can  never  obtain  in  the  two  classes. 

It  is  interesting  to  compare  different  views  on  this  question: 

1.  Air- workers'  union.     Stipulations  for  caisson  work. 

3^^  and  3^^  hours  to  -|-2  2  lb. 

3      and  3      hours  to  -I-33  lb. 

2      and  2      hours  to  -H35  lb. 

i}^  and  1 3'^  hours  to  -I-40  lb. 

40      and  40  minutes  to  -^45  lb. 

2.  Rules  proposed  by  21  engineers,  contractors  and  doctors  and  submitted 
to  the  N.  Y.  State  Labor  Commission. 


COMPRESSED-AIR   ILLNESS  203 

S  and  5  hours  to  +20  lb. 

8  hours  with  3^  hour  for  lunch  to  +32  lb. 
3  and  3  hours  to  +40  lb. 

3.  Ordinary  time  limits  for  divers  (Admirality  Committee). 

Over  3  hours  to  +26J-^  lb. 

3  hours  to  +2g}/^  lb. 

ij^  hours  to  +34K  lb. 

I  hour  to  +40  lb. 

4.  Haldane  who  was  on  the  Admiralty  Committee,  however,  prepares  his 
decompression  table  for  caisson  and  tunnel  work  on  the  basis  of  two  3-hour 
shifts  up  to  +45  lb.  pressure.  We  personally  believe  that  two  4-hour  shifts 
up  to  -j-32  lb.,  and  3-hour  shifts  up  to  -f-35  lb.,  and  two  2-hour  shifts  up  to 
+40  lb.  are  not  unreasonably  long,  nor  unduly  short,  and  we  believe  that 
proper  decompression  will  permit  longer  shifts. 

Keays  believes  that  6  hours  continuous  shift  is  preferable  to  two  3-hour 
shifts  as  it  exposes  the  man  to  the  risks  of  only  one  decompression  instead 
of  two,  for  he  considers  that  the  man  is  practically  saturated  in  3  hours  and 
therefore  the  prolongation  of  his  exposure  does  not  add  to  the  saturation. 

E.  Method  and  Duration  of  Decompression. — This  is  by  far  the  most 
important  element  in  prophylaxis,  and  as  it  is  a  matter  fully  under  control 
we  look  to  it  for  the  best  possible  solution  of  the  whole  question. 

The  two  methods  of  regulated  decompression  are  known  as  the  Uniform 
and  the  Stage  methods. 

I.  Uniform  decompression  is  the  older  and  almost  universally  practised 
method  and  consists  in  reducing  the  pressure  at  a  constant  and  uniform  rate, 
e.g.,  I  lb.  per  minute,  2  lb.  per  minute,  etc. 

I  will  mention  some  practical  illustrations;  to  wit, 


1839,  Douchy  mines 

1885,  Bridge  over  Eider  . . 

1895,  Nussdorf  bridge 

^1906,  Amsterdam  viaduct 
1908,  East  River  tunnels  . 


For  -}-iS  lb. 
For  +22,^  lb. 
For  -I-30  lb. 
For  -I-37M  lb. 

A  few  years  ago  New  York  State  adopted  the  following  regulations  for 
tunnel  work: 

*The  Amsterdam  work  was  conducted  on  this  basis  and  up  to  the  maximum  of  4-30  lb. 
pressure;  there  were  no  fatalities  but  there  were  229  cases  of  "bends." 


Max. 

pressure           Uniform  decompression 

+37 

Klb. 

30 

minutes 

+39 

lb. 

sM 

minutes 

+37K  lb. 

35 

minutes 

+30 

lb. 

32M 

minutes 

+42 

)ass( 

lb. 
id  as 

15 

22K 
32. s 
42.5 

21 

follows : 

minutes 
minutes 
minutes 
minutes 

minutes (2  lb. 

per) 

204 


SPECIFIC    OCCUPATIONAL   DISEASES 

New  York  State  Law  for  Air  Work 


Gauge  pressure, 
pounds 


Time  under  pressure 


Interval  between  spells 


Uniform  de- 
compression, 
minutes 


0-28  8  hours  less  interval 

28~35  -99        2  spells  of  3  hours  each 

36-41.99  ]  2  spells  of  2  hours  each 

42-45  .99  I  2  spells  of  I  J^2  hours  each 
46-49 .99         2  spells  of  I  hour  each 


30  consecutive  minutes 

spent 

18 

in  open  air 

At  least  I  hour 

24 

At  least  2  hours 

42 

At  least  3  hours 

46 

At  least  4  hours 

50 

New  York  State  Law  for  Caisson  Work,  in  force  Sept.  i,  191 2: 
Time  of  Decompression  for  Caissons 

Time  of  decompression 
Uniform  decompression  (in  minutes) 

Up  to  10  lb.  pressure i 

Up  to  15  lb.  pressure 2 

Up  to  20  lb.  pressure 5 

Up  to  25  lb.  pressure • 10 

Up  to  30  lb.  pressure 12 

Up  to  36  lb.  pressure 15 

Up  to  40  lb.  pressure 20 

Up  to  50  lb.  pressure 25 

The  incidence  of  illness  and  the  mortality  has  veen  very  considerable  under 
the  older  method  of  decompression  (see  above). 

2.  Stage  Decompression.— 'HaldsLue,  together  with  Boycott  and  Damant, 
as  a  result  of  exhaustive  study  and  experimentation,  have  quite  recently  put 
forward  a  different  method  of  decompression,  the  aim  of  which  is  still  further 
to  minimize  the  dangers  of  compressed-air  work. 

This  method,  known  as  the  "Stage"  method,  has  been  adopted  by  the 
British  Admiralty  Committee  on  Deep  Sea  Diving. 

A  brief  theoretical  discussion  of  decompression  will  best  explain  the 
different  methods. 

Other  things  being  equal,  for  the  same  difference  in  pressure,  de-saturation 
of  the  tissues  (during  and  after  decompression)  will  occur  at  the  same  rate 
and  in  the  same  time  that  obtained  for  saturation. 

We  have  already  mentioned  that  saturation  does  not  occur  at  a  uniform 
rate  but  is  much  more  rapid  at  first,  i.e.,  22  per  cent,  in  5  minutes,  50  per  cent, 
in  25  minutes,  whereas  90  per  cent,  for  the  slower  tissues  requires  4  hours, 
and  for  complete  saturation  at  least  5  hours  according  to  Haldane,  or  9 
hours  according  to  Bornstein. 

Therefore  if  de-saturation  takes  as  long  as  saturation,  it  is  at  once  evident 
that  every  man  who  has  worked  at  +28  lb.  pressure  for  4  hours  and  then  de- 
compresses in  18  minutes  (see  N.  Y.  State  Law),  mUst  emerge  from  the  lock 
very  incompletely  de-saturated;  in  fact  Mr.  Japp^'  calculates  that  he  will 
have  a  maximum  air  saturation  of  his  body,  an  emerging,  of  25.7  lb. 


COMPRESSED-AIR   ILLNESS 


205 


Practically,  universal  experience  in  compressed-air  work  has  demonstrated 
that  no  cases  of  illness,  or  a  very  few  minor  cases,  will  develop  even  after  the 
most  rapid  decompression  from  pressures  up  to  +20  lb.  Allowing  5  lb.  as 
a  margin,  Haldane  concludes  that  it  is  impossible  for  any  bubbles  to  form 
after  decompression  however  rapid,  following  exposures  up  to  +15  lb.  In 
terms  of  absolute  pressure  this  amounts  to  a  sudden  decompression  from  30 
lb.  to  15  lb.  or  from  2  atmospheres  to  i  atmosphere. 

Haldane^  continues,  "now,  the  volume  of  gas  capable  of  being  liberated  on 
decompression  to  any  given  pressure,  is  the  same,  if  the  relative  diminution 
or  pressure  (absolute)  is  the  same." 

To  give  an  example:  the  reduction  of  pressure  from  45  lb.  gauge  pressure 
to  15  lb.  gauge  pressure  which  is  a  reduction  from  4  atmospheres  to  2  atmos- 
pheres absolute,  will  liberate  the  same  volume  of  gas  as  the  reduction  from 
15  lb.  gauge  to  atmosphere  (or  from  2  to  i  atmosphere  absolute).  If  no 
bubbles  can  form  in  the  latter  instance,  none  will  form  in  the  former;  hence 
Haldane  concludes  "that  the  absolute  air  pressure  can  always  be  reduced 
very  rapidly,  without  risk,  to  half  the  absolute  pressure  at  which  the  tis- 
sues are  saturated;"  but  from  this  point  onward  the  decompression  must  be 
very  slow,  in  order  that  the  air  pressure  in  the  tissues  may  never  be  more 
than  twice  the  gauge  pressure. 

Further  as  Boycott  says,  this  method  makes  fullest  use  of  the  permissible 
difference  of  pressure  to  get  rid  of  the  nitrogen  from  the  tissues. 

As  a  result  of  his  studies  and  his  experiments  with  divers,  Haldane  offered, 
and  the  Admiralty  Committee  adopted  the  following  "stage  decompression" 
table,  based  on  the  assumption  that  the  most  rapid  decompression  from  19 
lb.  gauge  pressure  is  without  risk,  i.e.,  from  2.3  atmospheres  to  i  atmos- 
phere absolute. 

Dr.  Haldane's  Rate  of  Decompression  in  Caisson  and  Tunnel  Works. 

(Extract  from  report  of  a  committee  appointed  by  the  Lords  of  the  Admiralty  on  deep 

water  diving,  August,  1907;  Eyre  and  Spottiswoode.) 


Working  pressure 

per  square  inch, 

pounds 


Number  of  minutes  for  each  pound  of  decompression  after  the  first 
rapid  stage 


After  first  3-hour 
exposure, 
minutes 


After  second  or  third 
3-hour  exposure,  show- 
ing an  interval  for  a  meal, 
minutes 


After  6  hours  or  more 
of  continuous  ex- 
posure, 
minutes 


*  In  this  table,  the  first  rapid  stage  of  decompression,  down  to  one-half 
the  absolute  pressure,  is  to  be  accomplished  in  3  minutes. 

Another  method  suggested  by  Haldane  for  tunnel  work  is  illustrated  by 

*  See  diagram  of  Haldane's  Method  I. 


2o6 


SPECIFIC    OCCUPATIONAL   DISEASES 


the  following.  Where  possible,  a  part  of  the  tunnel  is  maintained  at  a 
pressure  equal  to  half  the  absolute  pressure  in  the  heading.  The  men  now 
decompress  rapidly  to  this  half  pressure,  remain  in  this  "purgatorial 
chamber"  until  the  air  pressure  in  the  body  falls  to  19  lb.,  and  then  come  out 
by  a  second  3-minute  decompression.     (See  diagram  of  Haldane's  Method  II.) 


30 


Haldane's  a  20 
Method  I  o 


10 


\ 

\ 

\ 

\ 

DECOMPRESSING  FROM  40  LB.GAUGE  PRESSURE 
TO  ATMOSPHERE  AFTER  3  HOURS  IMMERSION. 
DR.  HALDANE'S  TABLE  FOR  DECOMPRESSION 

"" 

V, 

^ 

^^■^v,. 

p49  lb. 

^ 

A 

tnios 

ihere 

^ 

Sr 



Haldane's  .§ 
Method  II  I  20 
P. 


123  Minutes 


Fig.  s. 


In  view  of  his  conception  of  decompression,  Haldane  condemns  "uniform 
decompression"  on  three  separate  counts;  viz.:  (i)  no  use  is  made  of  the 
possibility  of  hastening  the  exit  of  nitrogen  from  the  tissues  by  putting  on 
the  greatest  permissible  stress;  (2)  "uniform  decompression,"  to  be  safe, 
must  be  so  prodigiously  slow  that  it  is  an  irrational  proceeding;  and  how- 
ever slow  it  be,  the  difference  between  the  tissue  pressure  and  the  gauge 
pressure  must  become  larger  and  larger;  (3)  following  a  short  exposure,  this 
method  merely  prolongs  the  exposure  to  effective  pressure. 

The  logic  of  Haldane's  "stage  decompression"  seems  irrefutable  and 
Boycott  and  Damant,  experimenting  with  goats,  employed  both  methods. 
Their  results  showed  fewer  cases  of  illness  (18  per  cent.)  and  no  deaths,  with 
the  stage  method,  whereas  there  were  more  cases  of  illness  (53  per  cent.) 
including  two  deaths,  with  the  uniform  method.  The  greatest  advantage 
of  the  stage  method  was  noted  after  short  exposures. 


I 


COMPRESSED-AIR    ILLNESS  207 

On  the  contrary,  Hill  and  Greenwood,  using  pigs  and  rabbits,  found  no 
evidence  of  superiority  of  the  stage  method  over  the  uniform  decompression. 

HilP-  concludes  that  there  is  some  evidence  in  favor  of  stage  decom- 
pression after  short  exposures,  but  not  a  decisive  superiority  after  long 
exposures,  and  he  adds  that  ''the  theory  is  a  captivating  one,  but  experi- 
ment has  not  brought  that  conclusive  support  which  was  to  be  expected." 

At  the  Elbe  tunnel  the  tw^o  methods  were  tried  out  in  caisson  work  at 
+30  lb.,  but  very  Uttle  advantage  could  be  demonstrated  for  the  "stage" 
method  as  compared  with  the  "uniform." 

Mr.  H.  Japp,^^  managing  engineer  of  the  East  River  tunnels,  recounts 
the  entire  freedom  from  serious  and  fatal  cases  in  a  series  of  23,000  de- 
compressions from  +40  to  42  lb.  at  a  period  in  the  construction  of  the  tunnels, 
when  a  modification  of  the  stage  method  was  enforced  by  reason  of  the 
erection  of  two  extra  bulkheads  (with  air  locks)  at  intervals  of  looo  ft. 

Three  hundred  and  thirty  men  were  employed  for  36  days,  working 
3  hours  on,  3  hours  off,  and  3  hours  on,  and  were  decompressed  in  the  follow- 
ing manner. 

Five  minutes  were  spent  in  the  first  air  lock  in  decompressing  from  -{-40 
to  +29  lb.;  then  followed  a  walk  of  1000  ft.,  occupying  10  minutes  before 
entering  the  second  lock  where  8  minutes  were  spent  in  reducing  the  pressure 
from  -f  29  to  +12M  lb.  (which  latter  is  half  the  original  absolute  pressure). 
Another  10  minutes  was  spent  in  walking  to  and  waiting  for  the  third  lock,  in 
which  15  minutes  were  employed  in  reducing  from  +i23-^  lb.  to  atmos- 
pheric pressure. 

Thus  a  total  of  48  minutes  was  taken  for  decompression  which  would 
have  required  90^^  minutes  by  Haldane's  method  (i),  or  123  minutes  by 
Haldane's  method  (2);  and  Mr.  Japp  calculates  that  the  maximum  air 
saturation  of  the  workers  upon  leaving  the  last  lock  was  27  lb. 

Hence  Mr.  Japp  concludes  that  it  is  practically  safe  to  decompress 
rapidly  from  pressures  up  to  +27  lb.,  and  has  prepared  the  following  tables 
for  "stage  decompression,"  by  which  the  maximum  air  saturation  of  the 
tissues  upon  emerging  shall  never  exceed  25  lb. 

Decompression  Table  Based  on  25  Lb.  M.^xtuum  Air  Saturation  of  Body  ox  Emerging 

(Prepared  by  H.  W.  Japp) 

r^  T,    J  Total  time  in  Total  time  in  Total  time  in  "  „*,^ot;^.,  ^f 

Gauge  Reduce  pressure  ^j^  ^^^^  ^^^^^  8  ^^^  i^^,j^  ^^^^^  ^i^  ,^^1^.  ^^^^^  ^  ^^l^'L^^/"^  °^ 

pressure.  in  3  minutes  to—  fours'  work.  hours' work,           hours'  work.      ,  „^£L°^ 

pounds                 pounds                     minutes  minutes                   minutes  poS 


276  9 

32           ^yi  I       zz 

35  10  

40  I2j^  


25 

35 
48 


42  isJi  !  51  I  37 

15 

17M 


45  15 I  42 

:  -7  I^  48 


25 
25 
25 

25 
25 
25 
25 


2o8 


SPECIFIC   OCCUPATIONAL  DISEASES 


Comparison  of  Uniform 

AND  Stage  Decompression 

Tunnel 
pressure 
(gauge), 
pounds 

Time  worked, 
hours 

Uniform  decom- 
pression (New 
York  State  Law) 
minutes 

Maximum   air    !   c+^„o  ^„™^™o     i     Maximum  air 

saturation  of     !   ^f„^^^^°?^S^^!,-  1     saturation  of 

body  on             Seabove^            b"'^^' ^'^ 

emerging.            '^minuter                emerging. 

pounds                   .iiiiiu..ca                   pounds 

28.0 
36.0 
41.99 

45-99 
50.0 

S^i  and  3% 
3      and  3 
2      and  2 
I  }4  and  I K 
I      and  I 

18% 

24 

42 

46 

50 

25.70 
30.25 

31-25 
32.00 
32.50 

1 
14             1               25 

36  25 

37  25 
35           1             25 
33                        25 

Japp's  table  provides  a  great  shortening  of  decompression  as  compared 
with  Haldane's  tables,  which  latter,  Hill  also  agrees  are  unnecessarily  long. 
As  compared  with  the  New  York  State  uniform  decompression  table,  there 
is  also  a  slight  shortening  in  time,  but  a  marked  advantage  in  the  maximum 
air  saturation  of  the  tissues,  on  emerging. 

Hill  recommends  one  stage  at  +8  lb.,  lasting  15  minutes,  after  a  shift 
at  +30  lb.,  and  5  minutes  given  to  completing  decompression;  also  one  stage 
of  30  minutes  at  +15  lb.  after  a  shift  at  +40  to  45  lb.,  with  10  minutes 
spent  in  completing  decompression. 

Von  Schrotter^  recommends  from  +30  lb.  to  reduce  in  3  minutes  to  +12 
lb.  and  then  takes  32  minutes  to  complete;  or  from  +45  lb.  reduce  to  +22^^^ 
lb.  in  3  minutes  and  takes  60  minutes  to  complete. 

Conclusions. — No  one  of  the  suggested  methods  of  decompression  is 
efficient  in  entirely  eliminating  cases  of  "bends,"  but  the  improved  methods 
should  certainly  minimize  the  serious  and  fatal  cases. 

Indeed  in  Mr.  Japp's  series  of  23,000  decompressions  by  the  modified  stage 
method,  there  was  an  unusually  large  percentage  of  minor  cases;  for,  reporting 
on  8510  of  these  decompressions,  Keays  found  1.6  +  per  cent,  of  minor  cases, 
and  only  seasoned  men  were  employed. 

However  the  writer  believes  that  Mr.  Japp's  table  is  reasonably  safe  and 
is  the  most  practical  of  those  yet  devised. 

Exercise  during  and  after  decompression,  also  the  inhalation  of  oxygen 
in  the  last  period  of  decompression  and  following  it,  are  claimed  by  Hill  and 
others  to  greatly  hasten  the  elimination  of  nitrogen.  (N.  B. — The  inhalation 
of  pure  oxygen  under  pressures  above  +30  lb.  is  irritant  to  the  lungs  and 
highly  dangerous.) 

2.  Active  Treatment. 

(a)  Recompression. — Had  infectious  diseases  as  wonderfully  a  specific 
treatment  as  has  compressed-air  illness,  the  practice  of  medicine  would  be 
revolutionized. 

To  behold  a  man  paralyzed  from  the  waist  down,  carried  into  the  medical 
lock,  or  recompression  chamber;  the  pressure  raised,  and  within  5  minutes  to 
see  this  man  get  down  from  his  couch  and  walk  about,  is  indeed  little  short 
of  miraculous  and  yet  this  is  of  no  uncommon  occurrence. 


COMPRESSED-AIR   ILLNESS 


209 


Recompression  as  a  method  of  treatment  arose,  first,  among  the  workers 
themselves,  who  found  by  experience  that  their  pains  were  reUeved  upon  re- 
entering the  caisson  or  tunnel. 

To-day  every  properly  equipped  compressed-air  works  should  be  supplied 
with  one  or  more  specially  constructed  recompression  chambers  called 
"medical  air  locks,"  which  should  be  arranged  with  two  compartments,  thus 
permitting  the  medical  attendant  to  enter  or  leave  without  disturbing  the 
pressure  in  the  medical  chamber.  Such  locks  are  fitted  with  electric  lights, 
steam  heat,  clock,  pressure  gauge,  telephone,  and  comfortable  couches,  also 
there  is  a  glass  port  in  the  door  which  allows  observation  from  the  outside. 

1.  Theory  of  recompression. 

If  symptoms  are  due  to  the  liberation  of  bubbles  of  nitrogen  in  the  tissues 
and  body  fluids,  then  recompression  will  at  once  reduce  the  size  of  these 
bubbles  and  moreover,  will  urge  them  again  into  harmless  solution  in  the 
tissues,  and  if  decompression  now  be  carried  on  at  an  appropriate  rate,  the 
nitrogen  will  be  given  off  into  the  alveoli,  by  means  of  the  circulating  blood 
and  without  the  formation  of  bubbles. 

2.  Degree  of  pressure  for  recompression  treatment. 

At  the  East  River  tunnels,  it  was  the  practice  to  raise  the  pressure  to  the 
equivalent  of  the  tunnel  pressure,  and  then  at  once  to  start  decompression  at 
a  rate  not  exceeding  2  minutes  per  pound;  but  the  best  results  were  obtained 
by  a  rather  rapid  decompression  from  e.g.,  +32  lb.  to  +1^  lb.  and  thereafter 
very  slow  reduction  to  the  atmospheric  pressure,  60  to  90  minutes  or  even  two 
hours  being  sometimes  thus  employed  (This  will  be  seen  to  be  a  modification 
of  the  stage  decompression). 

Other  men  (L.  M.  Ryan^^),  claim  that  good  results  are  obtained  by  raising 
the  pressure  to  only  two-thirds  of  the  working  pressure,  and  allowing  i  hour 
for  reduction  from  H-i5  lb.,  and  3  to  4  hours  for  reduction  from  -f  20  lb.,  in 
severe  cases. 

In  criticism  of  Ryan's  suggestion,  although  admitting  that  pains  will  often 
disappear  long  before  the  full  pressure  is  reached,  the  writer  believes  with 
Haldane  that  the  first  rapid  stage  of  decompression  from  the  full  pressure  will 
aid  "  the  exit  of  the  nitrogen  by  making  use  of  the  greatest  permissible  stress;" 
and  therefore  full  pressure  should  be  employed. 

3.  Time  of  administration  of  recompression  treatment. 

By  far  the  best  results  attend  recompression  when  instituted  as  soon  as 
possible  after  the  onset  of  symptoms,  although  partial  or  complete  relief  often 
is  obtained  after  a  lapse  of  hours  or  even  a  whole  day. 

4.  Practical  results  of  recompression. 

Keays^  showed  that,  in  our  3692  cases,  about  90  per  cent,  were  com- 
pletely relieved  by  recompression.  Some  required  two  or  more  treatments, 
but  68  per  cent,  were  relieved  by  a  single  recompression. 

About  9  per  cent,  more  were  partially  relieved  and  only  0.5  per  cent,  failed 
to  get  any  relief. 
14 


2IO  SPECIFIC    OCCUPATIONAL    DISEASES 

Even  in  the  cases  of  partial  paralysis  of  the  legs  (i8  cases)  12  cleared  up 
entirely  with  one  recompression;  and  of  the  16  cases  of  complete  paraplegia, 
seven  were  cured  by  one  recompression. 

Of  cases  with  collapse  and  unconsciousness  (17  cases),  eight  were  relieved 
by  one  or  two  recompressions,  but  nine  were  fatal. 

(b)  Adjuvant  and  Palliative  Measures. 

Exercise  and  massage  and  the  inhalation  of  oxygen  both  in  and  out  of  the 
medical  locks  will  aid  elimination  of  nitrogen. 

Counter-irritation,  heat,  electricity,  liniments  and  massage  may  suffice 
in  many  minor  cases  of  "bends  "even  without  recompression,  or  may  be  used 
as  adjuvants  in  refractory  cases. 

Ergot  was  recommended  by  Dr.  A.  H.  Smith, ^  but  I  have  never  seen  any 
benefit  from  its  use,  and  moreover  the  indications  for  its  administrations  were 
based  upon  the  discarded  mechanical  pressure  theory. 

Symptomatic  medical  treatment  will  be  indicated;  e.g.,  anodynes  in  cases 
of  unrelieved  pain  and  hypodermatic  stimulation  in  cases  of  collapse  with 
impending  circulatory  or  respiratory  failure. 

REFERENCES 

'  Pol  and  Wattelle. — "  Memoire  sur  les  effets  de  la  compression  de  I'air."     Annales  d'hyg. 

publ.  et  de  med.  legale,  Paris,  1854. 
^  Paul  Bert. — "La  Pression  Barometrique,"  Paris,  1878. 
'  Jaminet. — "Physical  Effects  of  Compressed  Air,"  St.  Louis,  1871. 
■*  Snell. —    The  Compressed-air  Illness  or  Caisson  Disease,"  London,  1896. 
^  A.  H.  Smith. — "  Caisson  Disease."     Presby.  Hosp.  Reports,  New  York,  1895. 

*  Heller,  Mager,  von  Schrotter. — "Luftdruckerkrankungen,"  Vienna,  1900. 

^  Haldane. — "The  Hygiene  of  Work  in  Compressed  Air."     Jour.  Soc.  of  Arts.,  Vol.  XVI, 
No.  I,  Jan.  1908. 

*  Keays. — '  Compressed-air  Illness,"  New  York,  1909. 

"  Erdman. — "  .A.eropathy  or  Compressed-air  Illness,"   Journ.  Am.   Med.  Assn.,  Nov.  16, 

1907,  Vol.  XLIX,  page  1665. 
^^  McWhorter. — "The  Etiological    Factors   of   Compressed-air   Illness."     Am.  Journ.   of 

Med.  Sc,  March,  1910. 
"  Stettner. — "  Uber  Caissonkrankheit."     Wurzburger  Abhandl.,  Band  XI,  Heft  12,  1911. 
12  Hill. —    Caisson  Sickness,"  London,  191 2. 
*^  Japp. — "Caisson  Disease  and  Its  Prevention."     Trans.  15th  Intern.  Cong.  Hyg.  and 

Demog.,  Washington,  191 2,  Vol.  III. 
"  Silberstern. — "  DieGefahren  der  Caissonarbeit."      Vol.  Ill,   Trans.  15th  Intern.  Cong. 

Hyg.  and  Demog.,  Washington,  191 2. 
'*  Erdman. — "  Acute  Effects  of  Caisson  Disease."     Vol.  Ill,  Trans.   15th  Intern.   Cong. 

Hyg.  and  Demog.,  Washington,  191 2. 
'■^  Macleod. — "Hygiene  of  Work  in  Compressed  Air."     Vol.  II,  Trans.  15th  Intern.  Cong. 

Hyg.  and  Demog.,  Washington,  1912. 
1^  Ryan. — '  Compressed-air  Illness  in  Caisson    Work."     Am.  Labor  Legislation  Review, 

Vol.  II,  No.  2,  New  York,  June,  191 2. 
^*  Bassoe. — "Late  Manifestations  of  Caisson  Disease."     Vol.  Ill,  Trans.  15th  Intern.  Cong. 

Hyg.  and  Demog.,  Washington,  1912. 


CHAPTER  IV 
EFFECTS  OF  DIMINISHED  ATMOSPHERE  UPON  HEALTH 

BY  GEORGE   M.  KOBER,   M.  D.,  Washington,  D.  C. 

The  effects  of  diminished  atmospheric  pressure  and  physical  exertion  in 
mountain  climbing  upon  the  heart  and  respiratory  organs,  characterized  by 
rapid  and  difficult  breathing,  palpitation  of  the  heart,  headache,  dizziness, 
faintness,  nausea,  extreme  muscular  fatigue,  and  occasional  hemorrhage 
from  the  nose,  gums  and  ears,  have  been  known  for  some  time.  These 
symptoms  have  been  observed  in  persons  not  accustomed  to  a  rarified  at- 
mosphere in  altitudes  of  2000  to  3000  meters,  and  higher  elevations 
naturally  intensify  the  effects. 

While  some  of  these  effects  may  be  clearly  traced  to  diminished  atmos- 
pheric pressure  and  deficiency  of  oxygen,  muscular  exertion  and  fatigue  toxins 
doubtless  also  play  an  important  role.  Mountain  climbing  involves  lifting 
the  entire  weight  of  the  body  through  the  distance  climbed,  which  for  a  man 
weighing  175  lb.  is  equivalent  to  about  8  ft.-tons  of  work  for  every  90  ft.  eleva- 
tion. Hence  work  of  this  character,  or  any  muscular  exertion  such  as  mining 
and  construction  work,  involves  increased  production  of  waste  material  in 
the  blood,  and  doubtless  accounts  for  the  insomnia,  loss  of  appetite  and 
chronic  fatigue  observed  among  the  miners  and  other  workers  in  high  alti- 
tudes. The  heart  and  lungs  gradually  adapt  themselves  to  the  diminished 
atmospheric  pressure,  the  vital  capacity  of  the  lungs  is  increased  in  conse- 
quence of  deeper  inspirations,  and  there  is  much  reason  for  assuming  that  the 
functions  of  the  hemopoietic  organs  are  also  gradually  increased  in  high 
altitudes.  The  most  recent  investigations^  show  that  the  number  of  red 
blood  corpuscles,  the  amount  of  hemoglobin  or  coloring  matter  and  the 
amount  of  oyxgen  in  the  blood  are  distinctly  higher  than  the  "normals" 
of  sea  level.^  In  spite  of  this  beautiful  adaptation  it  is  evident  that  the  effi- 
ciency of  workers  is  greatly  impaired;  even  the  native  copper  miners  at  Cerro 
de  Pasca,  altitude  16,000  ft.,  according  to  Oliver,^  can  only  work  in  8-hour 
shifts  for  a  few  months  at  a  time,  when  they  are  obliged  to  cease  and  return 
to  their  farms. 

Ballooning. — It  has  been  generally  assumed  that  in  the  absence  of 
physical  exertion,  modifications  in  the  action  of  the  heart  and  lungs  are  less 
Hable  to  ensue  in  balloon  ascensions.  Petard  in  1873,  with  four  companions, 
found  this  to  be  true,  since  in  a  balloon  flight  the  phenomena  of  so-called 
mountain  sickness  were  not  observed  until  an  elevation  of  between  4000  and 
4690  meters  was  reached,  when  the  pulse  rate  was  114  and  respiration  44 
per  minute.     Von  Schrotter,*  since   1896,  has  made  a  number  of  balloon 


212  SPECIFIC    OCCUPATIONAL   DISEASES 

ascensions  and  determined  that  serious  symptoms  are  rarely  observed  in 
aeronauts,  except  in  specially  predisposed  subjects,  until  an  elevation  of 
5000  meters  is  reached. 

This  altitude,  and  higher  elevations,  he  regards  as  the  danger  zone  since, 
in  addition  to  the  cardiac  and  respiratory  symptoms,  there  is  also  great 
mental  depression,  and  the  slightest  muscular  effort,  such  as  unloading  a  sack 
of  ballast,  is  followed  by  faintness.  In  elevations  above  5000  meters  the 
pulse,  at  first  rapid,  becomes  small  and  irregular.  Dr.  Flemming  and  Steyrer,"* 
in  June,  191 1,  attained  an  elevation  of  8910  meters  and  experienced  extremely 
grave  symptoms,  such  as  diminished  cardiac  and  respiratory  action,  pulse 
almost  imperceptible,  cramps  and  tremblings  of  the  muscles,  diminished 
mental  and  spinal  sensibility,  cyanotic  countenance,  and  unconsciousness — 
symptoms  urgently  calling  for  the  use  of  oxygen  inhalations.  Most  authors 
agree  with  Zuntz  that,  while  these  symptoms  are  caused  by  a  deficiency  of 
oxygen  in  the  system,  the  'diminished  atmospheric  pressure  also  produces  a 
gaseous  distention  of  the  intestines  which  impinge  upon  the  diaphragm  and 
seriously  interfere  with  the  vital  capacity  of  the  lungs.  Nausea  with  oc- 
casional vomiting,  in  fact  all  of  the  symptoms  of  seasickness,  is  liable  to  occur 
at  any  elevation  if  the  movement  of  the  airship,  in  consequence  of  irregulari- 
ties of  the  winds  and  eddies,  has  become  unsteady. 

According  to  Dr.  Reymond,^  the  effects  of  aviation  on  the  ear  are  charac- 
terized by  a  painful  tension,  ringing  or  buzzing  noises  and  impaired  hearing. 
These  phenomena  are  due  to  differences  in  atmospheric  pressure,  and  hence 
are  more  pronounced  during  sudden  changes  in  elevation  and  after  a  rapid 
descent.  The  noise  from  motors  tends  to  aggravate  the  effects.  Airmen 
wear  suitable  caps  with  ear  mufflers,  and  some  have  also  resorted  to  plugs  of 
cotton,  but  this  additional  safeguard  had  to  be  abandoned  as  it  interfered 
with  observing  modifications  in  the  action  of  the  motor.  Ordinarily  the  act 
of  yawning  or  swallowing,  with  mouth  and  nose  closed,  serves  to  restore  the 
equilibrium  between  the  inner  and  outer  air  of  the  internal  ear.  The  tempo- 
rary deafness  varies  in  different  individuals  and  would  appear  to  go  off 
with  practice,  but  Reymond  found  that  cases  of  catarrh  of  the  Eustachian 
tube  are  greatly  aggravated,  especially  in  mouth  breathers,  on  account  of  the 
strong  winds,  and  require  more  active  treatment. 

The  effects  of  strong  air  currents  and  intensive  insolation  upon  the  eyes 
are  harmful.  The  activity  of  the  violet  and  ultra-violet  rays  is  greatly  in- 
creased in  high  elevations,  but  there  is  no  evidence  that  the  sense  of  vision  is 
in  any  way  impaired,  if  protective  glasses  are  worn. 

Sunburns  and  severe  forms  of  dermatitis  caused  by  intensive  insola- 
tion are  more  common  in  high  elevations,  but  may  be  prevented  by 
suitable  hoods  and  protection  of  the  hands  and  arms.  The  excessive  dry- 
ness of  the  upper  strata  of  the  air  causes  rapid  evaporation  of  perspiration 
and  pulmonary  exhalation,  and  may  produce  inflammatory  conditions  of  the 
skin  and  mucous  membranes,  especially  of  the  eyes  and  upper  air  passages. 


EFFECTS   OF   DIMINISHED   ATMOSPHERE   UPON   HEALTH  213 

The  eflfects  of  sudden  changes  in  temperature  and  exposure  to  extreme 
cold,  rain  or  hail  upon  the  system  cannot  fail  to  prove  injurious.  Von 
Schrotter  reports  flights  in  which  the  thermometer  registered  —40^0.  For- 
tunately the  air  is  practically  frozen  dry  and  the  effects  of  cold  are  less 
intense.  Nevertheless  exposure  to  extreme  cold,  fogs  and  atmospheric 
electricity,  and  the  modifications  in  respiration,  etc.,  are  doubtless  frequent 
causes  of  accidents. 

Among  the  occupational  risks  of  ballooning  should  be  mentioned  the 
possibility  of  "gas  poisoning."  Von  Schrotter^  refers  to  several  instances 
of  carbon  monoxide  poisoning  which  occurred  during  the  inflation,  deflation 
and  collisions  of  balloons.  Prof.  Glaister'^  of  the  University  of  Glasgow 
reports  16  cases  of  poisoning  from  arseniuretted  hydrogen  gas  which  occurred, 
in  balloonmg  for  military  and  other  purposes,  during  the  inflation  or  deflation 
of  the  balloons  or  from  leakage  during  balloon  flights  (see  page  8).  Similar 
cases  have  been  described  by  Dr.  Maljean^  of  the  French  Army  and  Crone^ 
of  the  Prussian  Army. 

Dirigible  Balloons. — Since  the  introduction  of  motors  in  dirigible  balloons, 
new  elements  of  danger  have  been  added,  such  as  gasoline  explosions,  breaks 
in  the  propeller,  failure  to  get  gasoline  into  the  cylinder  during  a  steep  in- 
cline of  the  apparatus,  etc.  But,  after  all,  the  accident  liability  in  balloon 
flights  is  not  as  great  as  has  been  geneirally  assumed.  According  to  Flem- 
ming,  cited  by  von  Schrotter,  during  the  year  1908  there  were  17 13  balloon 
flights  in  Germany  in  which  5786  persons  participated;  of  these,  50  persons 
were  injured,  four  or  0.07  per  cent,  resulted  in  death,  24  or  0.41  per  cent, 
in  serious  injuries,  and  22  in  slight  injuries. 

Aviators. — The  percentage  of  fatal  injuries  is  very  much  greater  among 
aviators.  We  have  no  precise  data,  but  the  statistics  compiled  up  to  April 
1,  1914,  show  that  462  aviators  have  been  killed  since  September  17,  1908, 
when  the  first  man,  Lieut.  Selfridge,  U.  S.  A.,^°  lost  his  life. 

According  to  Dr.  Reymond^^  "  the  greater  number  of  accidents  of  aviation 
are  due  to  the  apparatus,  to  the  imprudence  or  the  clumsiness  of  the  aviator, 
to  his  physiological  condition,  which  may  itself  be  caused  by  the  conduct  of 
the  apparatus;  but  it  would  be  premature  to  draw  conclusions  as  yet." 
The  physiological  effects  of  diminished  atmospheric  pressure  upon  the 
lungs,  heart,  etc.,  probably  because  of  the  more  rapid  flights,  are  observed 
in  very  much  lower  elevations  than  in  balloon  ascensions.  Some  interesting 
observations  were  made  on  this  point  by  Cruchet  and  Moulinier^^  during 
the  aviation  contest  at  Bordeau  in  September,  1910.  They  found  at  an 
elevation  of  1000  meters  an  increase  in  the  blood  pressure  of  between  30 
and  40  per  cent.,  and  the  action  of  the  heart  was  quite  rapid.  These  symp- 
toms were  not  noted  in  elevations  between  100  and  150  meters.  None  of  the 
flights  exceeded  an  elevation  of  3000  meters,  and  symptoms  such  as  palpita- 
tion of  the  heart,  earache  and  ringing  in  the  ears  and  vertigo  were  especially 
marked  in  rapid  descents.     Flemming'*  reports  two  cases  of  unconsciousness 


214  SPECIFIC    OCCUPATIONAL   DISEASES 

in  aviators,  which  occurred  at  an  elevation  of  between  loo  and  200  meters 
and  which  he  attributed  to  the  combined  influence  of  cold,  flatulent 
distention  of  the  bowels  and  passive  congestion,  caused  by  tight-fitting 
clothing. 

My  friend  Mr.  Douglas  McCurdy,  one  of  the  most  expert  and  intelli- 
gent of  American  aviators,  in  commenting  upon  the  effects  of  exposure 
to  extreme  cold  writes  me  as  follows;  "I  had  an  experience  while  flying  at 
Baddeck,  Nova  Scotia,  during  the  month  of  February,  1909.  The  tem- 
perature was  about  zero  and  of  course  I  was  warmly  clad.  I  had  flown 
about  10  miles,  landing  at  my  starting  point,  when  my  hands  seemed  un- 
usually cold.  I  then  felt  a  most  curious  feeling  come  over  me,  where  people 
and  sounds  right  around  me  seemed  distant.  I  broke  into  a  violent  per- 
spiration and  was  helped  into  a  doctor's  sleigh,  which  was  near  by,  and 
covered  up  with  warm  robes.  .This  most  delightful  sensation  lasted  for 
about  5  minutes  when  I  gradually  became  normal  again." 

The  psychic  factors  in  aviation  have  recently  been  studied  by  Loewy 
and  Placzek,^^  who  report  a  series  of  tests  of  the  attention  and  other  psychic 
phenomena  on  themselves  and  two  others  in  a  pneumatic  cabinet  with  an  at- 
mospheric pressure  corresponding  to  that  of  an  altitude  of  4000  meters. 
The  findings  are  summarized  as  follows:  The  objective  findings  were  com- 
paratively shght,  although  mistakes  in  doing  sums  were  more  frequent  the 
more  rarified  the  air.  But  the  sensation  of  being  incapable  of  giving  close 
attention,  of  being  unable  to  act  promptly  and  with  precision — these  sub- 
jective factors  were  pronounced,  and  even  a  subjective  sensation  of  the 
kind  has  always  more  or  less  of  a  paralyzing  effect  and  may  serve  to  ex- 
plain some  of  the  fatalities  to  aviators  for  which  the  machines  were  not 
responsible.  The  effects  in  these  tests  were  the  more  significant  as  the 
subjects  were  quiet,  warm  and  free  from  responsibility  in  the  pneumatic 
cabinet.  "  Compare  this  with  the  condition  of  the  aviator,"  they  remark, 
"  the  rapid  changes  in  altitude  causing  physical  disturbances  and  weaken- 
ing the  will  power,  while  the  wind  makes  it  hard  to  breathe  and  chills  the 
surface,  and  finally  paralyzes  the  peripheral  vessels  so  that  the  blood  pours 
into  them  and  the  brain,  etc.,  become  anaemic."  They  think  that  the  death 
of  Chavez,  for  instance,  was  due  to  these  causes,  as  he  strove  to  break  the 
altitude  record.  They  warn  aviators  against  high  altitudes  and  urge  them 
to  train  themselves  to  bear  abrupt  changes  in  atmospheric  pressure. 

Mr.  Earle  L.  Ovington,  an  expert  high  flyer  in  the  United  States,  pub- 
lished a  valuable  criticism  of  these  researches  which  may  be  summarized 
as  follows:  He  has  repeatedly  flown  at  heights  in  excess  of  4000  meters, 
(about  2} '2  miles),  believes  in  high  flying  and  considers  it  less  dangerous 
than  low  flying,  because  the  vertical  air  currents  which  are  dangerous  at 
low  altitudes  have  no  effect  at  great  heights.  He  believes  there  is  a  great 
difference  in  the  psychologic  condition  between  two  men  cooped  up  in  a  little 
cabinet  under  artificial  conditions  and  the  same  men  flying  free  through  the 


EFFECTS    OF    DIMINISHED    ATMOSPHERE    UPON    HEALTH  215 

clear  atmosphere  at  a  height  of  2  miles.  He  does  not  believe  that  the 
rarified  air  paralyzes  the  action  of  the  subjective  mind,  and  his  experience 
has  been  that  the  objective  mind,  at  least,  is  stimulated  by  the  excitement 
of  rushing  through  the  pure  air  at  high  speed,  and  possibly  by  the  greater 
actinic  power  of  the  sunshine  in  high  altitudes.  Mr.  Ovington  has  had 
no. difficulty  in  breathing  in  an  aeroplane  at  a  speed  of  over  150  miles  an 
hour  (with  the  wind,  of  course),  and  states  "that  an  aeroplane  properly 
designed  is  so  constructed  that  a  great  deal  of  this  wind  is  done  away 
with."  He  has  not  found  that  rarification  of  the  air  interferes  with 
breathing  owing  to  the  fact,  as  he  believes,  that  the  aviator  climbs  so  slowly  that 
he  has  plenty  of  time  to  get  used  to  the  diminished  atmospheric  pressure. 
He  describes  the  bad  effects  of  rapid  descents  as  follows:  "If  I  cut  off  my 
engine  at  a  2-mile  height  and  drop  suddenly  to  a  mile  from  the  ground, 
it  seems  as  if  some  one  was  standing  behind  me  poking  red  hot  pokers  into  my 
ears.  .  .  .  My  usual  practice,  when  I  wished  to  avoid  this  incon- 
venience, was  to  drop  1000  ft.  as  slowly  as  possible  with  the  power  off,  turn 
on  the  power  and  circle  around  at  that  level,  swallowing  vigorously.  I 
would  then  drop  another  1000  ft.  In  this  way  I  could  get  to  the  ground 
from  a  height  of  2  miles  without  any  inconvenience.  ...  At  Columbus 
I  thought  I  would  do  a  little  grand-stand  work  and  drop  from  the  height  of  a 
mile  straight  to  the  ground  as  rapidly  as  possible.  I  stepped  out  of  the 
machine  with  everything  swimming  before  my  eyes  and  just  as  my  foot 
touched  the  ground  I  became  unconscious  and  remained  unconscious  for 
5  minutes  or  so.  This  was  no  doubt  due  to  the  rapidity  of  my  descent,  and 
this  may  have  caused  Chavez  to  lose  control  of  his  machine  when  only  100 
ft.  from  the  ground." 

Whatever  difference  of  opinion  there  may  be  as  to  the  ability  of  the  mind 
and  body  to  accommodate  itself  to  the  effects  of  diminished  atmospheric 
pressure,  and  much  of  this  doubtless  depends  upon  inherent  qualities  of  the 
aviator,  prudence  demands  that  rapid  ascents  and  descents  should  be 
avoided. 

That  there  is  special  danger  in  sudden  descents  is  apparent  from  the 
facts  already  stated,  and  is  also  evident  from  the  following  personal  note  by 
Mr.  McCurdy  upon  the  death  of  Archie  Hoxey  at  Los  Angeles,  California. 
He  writes:  "Mr.  Hoxey  was  one  of  the  most  expert  of  flyers,  and  had  given 
a  good  deal  of  attention  to  high  flying  (about  11,000  ft.).  He  had  experienced 
at  several  times  a  dizzy  sensation  and  a  shght  feeling  of  nausea  upon  landing, 
due  we  thought  to  a  too  rapid  descent.  We  cautioned  him  and  advised  a 
slower  rate  of  descent,  but  he  paid  no  heed.  At  the  time  of  which  I  speak  he 
had  attained  an  altitude  of  about  11,000  ft.  and  came  down  very  rapidly  to 
about  300  ft.,  when  the  machine  was  observed  to  continue  an  abnormal  de- 
scent and  Mr.  Hoxey  seemed  to  have  abandoned  his  controlling  levers. 
The  machine  finally  struck  the  ground  and  Hoxey  was  killed.  He  had  made 
apparently  no  effort  to  land  normally." 


2l6  SPECIFIC   OCCUPATIONAL  DISEASES 

Preventive  Measures. — The  general  symptoms  observed  in  ballooning  and 
aviation  clearly  indicate  that  airmen  should  have  sound  eyes,  ears,  heart  and 
lungs.  Dr.  Reymond  refers  to  an  aviator  with  a  heart  lesion,  and  another 
afflicted  with  pulmonary  tuberculosis  in  the  second  stage;  in  both  of  these 
cases  the  symptoms  were  not  aggravated  by  the  continuous  practice  of  avia- 
tion; "asthmatics  and  emphysematous  subjects,  on  the  other  hand,  suffer 
very  much  from  the  wind  raised  by  the  screw  or  from  the  speed  of  the 
relative  air  current." 

Referring  to  the  effects  of  aviation  on  diseased  lungs,  Mr.  McCurdy  in- 
forms me  that  Mr.  Hubert  Latham  of  France  was  practically  given  up  by  his 
physicians  as  he  was  suffering  from  consumption.  He  therefore  decided  that 
he  might  as  well  have  some  excitement  for  the  remaining  few  months  of  his 
life  by  flying.  He  became  connected  with  the  Antwanette  Co.,  the  makers  of 
the  beautiful  monoplane  which  bears  their  name,  and  soon  became  the  most 
expert  flyer  in  the  world.  He  was  in  the  open  air  so  much  that  he  almost 
completely  recovered  his  normal  health  and  lived  for  several  years.  He  was, 
however,  killed  by  a  wild  bull  while  hunting  in  Madagascar  in  191 2. 

It  is  apparent,  however,  that  only  physically  sound  persons  should  en- 
gage in  this  work,  which  is  full  of  possibilities  in  the  future.  All  ascending 
and  descending  flights  should  be  made  gradually  and  all  elevations  above 
1500  meters  should  be  avoided.  A  reserve  pilot  should  always  be  on  duty 
to  render  first  aid.  An  apparatus  for  the  administration  of  oxygen  is  indis- 
pensable. Dr.  E.  KoscheP^  reports  that  his  pulse  in  the  flights  of  191 1  was 
140  at  an  elevation  of  5000  meters  and  160  at  an  altitude  of  6000  meters. 
In  191 2  by  resorting  to  timely  oxygen  inhalation,  at  an  elevation  of  3500 
meters,  he  attained  and  remained  in  altitudes  between  7500  and  9000  meters, 
with  a  pulse  not  exceeding  100  per  minute  and  was  perfectly  capable  of 
physical  exertion,  such  as  unloading  sacks  of  sand  ballast.  Protection  for 
the  head  and  eyes  is  necessary  not  only  against  excessive  insolation  but  also 
in  case  of  rain,  hail  and  snowstorms. 

Flemming  has  pointed  out  the  dangers  of  tight-fitting  clothing.  Several 
thicknesses  of  light  woolen  clothing,  loosely  draped  with  some  impermeable 
outer  garment,  woolen  socks  and  felt  boots  offer  the  best  protection  against 
cold  and  winds. 

REFERENCES 

^  Cohnheim,  O.,  and  Weber. — Die  Blutbildung  in  Hochgebirge.    Deutsches  Arch.  f.  Klin. 

Med.,  1913,  CX,  225. 
"  Anglo-Am.  Exped.  to  Pikes  Peak.     J.  A.  M.  A.,  Aug.  10,  191 2,  page  449. 
'  Oliver. — Diseases  of  Occupation,  London,  1908,  page  118. 

*  Von  Schrotter,  Hermann. — Hygiene  d.  Aeronautick  und  Aviatick,  Wien,  191 2. 

*  Reymond. — Journ.  State  Medicine,  London,  1913,  Vol.  XXI,  pages  500-503. 

*  Von  Schrotter. — Loc.  cit.,  pages  45,  46. 

'  Glaister,  John. — Actes  du  II  Congres.  Internat.  des  Maladies  Professionneles,  Bruxelles, 
1912. 

*  Maljean. — Archives  de  Med.  et  de  Pharm.  Milit.  Vol.  XXXV,  p.  82. 


EFFECTS    OF   DIMINISHED   ATMOSPHERE   UPON   HEALTH  217 

'  Crone. — Deutsche  ]Militararztl.     Zeitschft,  Vol.  XXIX,  1900,  page  139. 
'"  Boston  Medical  and  Surgical  Journal,  1913,  CLXIX,  page  365,  and  Press  Reports. 
"  Reymond. — Loc.  cit. 

^^  Dastre  M.  A. — Comptes  rendus,  Acad.  d.  Sc,  Paris,  191 1,  Vol.  CLII,  page  11 14. 
1'  Berliner  Klin.  Wochnschft.,  June  i,  1914.     Abstract  J.  A.  M.  A.,  July  11,  1914,  page  203. 
"  Flemming. — Deutsche  Med.  Wochnschft.,  1912,  Vol.  XXXVIII,  2,  page  1338. 
^^  Koschel  E. — Jahrbuch  der  wissenschaftlichen  Gesellschaft  f.  Flugtechnick,  Vol.  II,  Part 
2,  1914. 


DIVISION  n 
Systemic  Occupational  Diseases 

CHAPTER  I 
DUST  DISEASES  OF  THE  LUNGS 

BY  SIR  THOMAS  OLIVER,  M.D.,  Newcastle-upon-Tyne,  England 

That  pulmonary  disease  develops  with  greater  frequency  in  persons  fol- 
lowing certain  occupations  compared  with  others  has  long  been  known.  The 
circumstance  did  not  escape  the  attention  of  Ramazzini  200  years  ago.  A 
century  ago  physicians  in  Great  Britain  were  more  familiar  with  the  phthisis 
of  coal  miners  than  is  the  present  generation.  Colliers  became  the  subjects 
of  cough,  they  emaciated,  they  expectorated  large  quantities  of  an  inky  black 
material,  and  after  death  the  lungs  were  found  to  be  absolutely  black  and 
cavitated.  Our  knowledge  of  the  disease  goes  back  to  181 5  when  Pearson 
presented  a  paper  to  the  Royal  Society  of  London  upon  the  subject.  In 
1 83 1  Gregory  and  Chris tesin  of  Edinburgh  extracted  from  the  lungs  of  coal 
miners  dying  from  phthisis  black  material  which  they  found  to  be  carbon. 
The  dark  color  of  miners'  lungs  had  been  regarded  by  Laennec  as  the  result  of 
smoke  from  the  lamps,  but  by  Behier  in  1837  and  Rilliet  in  1838  it  was  attrib- 
uted to  particles  of  carbon.  Belgian  colhery  doctors,  among  whom  Gobert 
of  Hainaut  (1827)  and  Kuborn  of  Liege  (1861)  may  be  mentioned,  were 
familiar  with  the  asthma  of  miners  and  its  accompanying  black  spit.  Another 
explanation  of  the  discolored  lungs  of  miners  was  ofifered  by  Virchow.  The 
pigmentation  arose  according  to  him  from  a  transformation  of  the  hematine 
of  extravasated  blood.  It  is  needless  to  say  that  Virchow's  theory  has  few 
exponents. 

The  malady  is  known  as  anthracosis  or  coal  miners'  phthisis.  Miners 
working  in  certain  coal  fields  are  more  affected  than  others,  a  circumstance 
which  suggests  that  the  physical  character  of  the  coal  plays  an  important  part 
in  the  development  of  the  illness,  some  coals  being  harder  than  others.  From 
a  historical  point  of  view  the  opening  out  of  the  South  Wales  coal  fields  is  a 
modern  development  compared  with  those  of  Northumberland,  but  owing  to 
the  smokeless  character  of  the  coal  and  its  suitability  for  steamship  purposes 
the  industry  received  an  impetus  half  a  century  ago  which  has  not  yet  begun 
to  decline.  When  Sir  John  Simon  wrote  upon  the  subject  nearly  50  years 
ago  he  was  of  the  opinion  that  there  was  a  larger  amount  of  bronchial  and 
respiratory  disease  among  the  Welsh  miners  than  among  the  Northumber- 

218 


DUST    DISEASES    OF    THE    LUNGS  219 

land,  a  circumstance  which  he  attributed  to  the  better  ventilation  of  the 
mines  in  the  North  of  England.  To-day  ventilation  of  coal  mines  in  all  the 
civilized  world  is  good  and  as  a  consequence  the  health  of  coal  miners  is 
satisfactory. 

This  is  particularly  so  as  regards  tuberculosis.  British  coal  miners  do 
not  exhibit  a  high  mortality  rate  from  this  disease  compared  with  men  work- 
ing in  most  other  trades.  Taking  the  tuberculosis  mortality  figures  of  all 
occupied  males  in  England  and  Wales  as  175,  that  of  coal  miners  is  only  85. 
In  the  United  States  the  death  rate  from  all  causes  among  miners  and  quarry- 
men  (the  two  occupations  are  linked  together)  is  120.9  P^^  100,000  living, 
for  lawyers  139.9,  for  physicians  and  surgeons  168.8,  for  carpenters  and  joiners 
231.0,  and  for  marble  and  stone  cutters  540.5.  According  to  the  same  census, 
pulmonary  consumption  caused  10.6  per  cent,  of  deaths  of  all  miners  and 
quarrymen  as  against  16.2  for  all  occupied  males.  At  Scranton,^  U.  S.  A., 
during  10  years  pulmonary  tuberculosis  caused  3.37  per  cent,  of  all  deaths 
and  among  all  other  occupied  males  9.97  per  cent.  Of  lung  diseases  alone 
tuberculosis  caused  14  per  cent,  of  all  deaths  among  anthracite  miners  in 
Scranton  and  41  per  cent,  of  deaths  among  other  occupied  males.  This 
comparative  freedom  of  the  coal  miner  from  tuberculosis  has  raised  the 
question  as  to  whether  some  protective  influence  is  not  exercised  by  coal  dust 
upon  the  lungs.  From  their  experiments  upon  animals  Wainwright  and  Nich- 
ols were  disposed  to  attribute  a  certain  amount  of  protection  to  the  lungs 
against  tuberculosis.  Nichols  regards  the  calcium  salts  in  coal  dust  as  the 
protecting  agent.  It  is  certainly  astonishing,  for  example,  how  rapidly 
wounds  in  coal  miners  heal. 

While  we  admit  that  the  comparatively  good  health  and  longevity" of  the 
coal  miner  are  the  result  of  the  improved  ventilation  of  recent  years,  there  is 
just  the  possibility  that  excessive  ventilation  by  overdrying  the  air  of  mines 
raises  and  carries  onward  very  fine  dust  which  may  not  only  do  damage  to 
the  lungs  of  those  who  inhale  it  but  may  also  become  a  cause  of  explosion  in 
the  mine.  If  the  work  of  a  coal  miner  is  hard,  his  hours  are  not  long  compared 
with  other  occupations  and  the  atmosphere  in  which  he  works,  if  in  the  line 
of  the  intake  air,  is  satisfactory.  It  is  whe«''men  are  working  at  the  face, 
in  confined  places  and  away  from  the  immediate  delivery  of  air,  that  they 
are  Hable  to  be  injured  by  dust.  The  more  confined  the  space  and  the  less 
readily  the  atmosphere  can  be  cleared  of  fume  and  dust  raised  by  the  use  of 
explosives  to  bring  down  the  rock,  the  greater  is  the  liability  of  the  men  to 
become  the  subjects  of  pulmonary  disease.  To  the  various  forms  of  disease 
of  the  lungs  caused  by  inhalation  of  dust  the  term  pneumokoniosis  was  ap- 
plied by  Zenker — from  the  Greek  word  pneumon,  lung,  and  konis,  dust.  Al- 
though the  kind  of  dust  inhaled  directs  the  type  of  the  pulomonary  lesion, 
yet  one  pathological  substratum  underlies  all  forms  of  the  disease,  viz., 
fibrosis  or  a  replacement  of  the  elastic  tissue  of  the  lung  by  an  unyielding 
fibro-connective  tissue.     The  fibrosis  imparts  solidity  to  the  lung  and  abridges 


220  SYSTEMIC    OCCUPATIONAL   DISEASES 

its  aerating  function.  To  the  black  lung  of  the  coal  miner  as  already  stated 
the  term  anthracosis  is  applied,  to  the  gray-black  lung  of  the  stone  cutter 
chalicosis  is  given,  to  that  of  the  gold  miner  silicosis,  and  to  the  lung  of  the 
worker  in  metal  dust  the  term  siderosis  is  applied.  The  lungs  of  persons  who 
live  in  large  towns  are  always  more  deeply  pigmented  than  those  of  persons 
living  in  the  country,  and  on  microscopical  examination  the  cause  of  the  pig- 
mentation is  invariably  found  to  be  particles  of  carbon  or  other  kinds  of  dust. 
In  a  dusty  atmosphere  it  is  the  finer  particles  which  reach  the  lungs  and 
damage  them.  The  heavier  particles  are  apt  to  be  caught  in  the  nares  and 
upper  portion  of  the  respiratory  tract  and  to  be  expelled  in  coughing.  The 
ciliated  epithelium  of  trachea  and  bronchii  is  a  defensive  barrier  to  the  lungs, 
since  dust  caught  in  the  mucus  secreted  by  the  tubes  is  by  the  waving  action 
of  the  ciliated  epithelium  wafted  outward.  Recurrent  colds  lead  to  a  shed- 
ding of  the  ciliated  epitheliiftn  and  with  this  desquamation  an  important 
defense  is  lost  to  the  lungs.  This  circumstance  is  not  without  importance 
since  recurrent  catarrh  of  the  upper  respiratory  passages  is  a  frequent  prelude 
to  pneumokoniosis. 

So  far  as  coal  miners'  phthisis  is  concerned  it  may  be  stated  that  a  collier 
who  develops  anthracosis  may  live  for  years  and  be  little  inconvenienced  by 
his  malady.  This  applies  only  to  the  man  who  has  worked  in  soft  coal. 
It  is  otherwise  if  the  coal  has  been  of  a  hard,  gritty  and  stone-like  nature. 
Miners  keep  bringing  up  large  quantities  of  black  spit  for  years  after  they 
have  ceased  working  in  coal — a  circumstance  which  shows  not  only  that 
considerable  deposits  of  carbon  had  taken  place  in  the  lungs,  but  that  the 
lungs  tend  to  rid  themselves  of  the  deposited  carbon  largely  by  means  of  the 
action  of  pulmonary  phagocytes.  It  cannot  be  said  of  coal  miners  that  they 
are  an  unhealthy  class  of  men.  Far  from  it;  apart  from  the  risks  of  mining 
their  prospects  of  longevity  are  good.  In  a  country  like  South  Africa  a 
comparison  can  be  made  between  the  harmlessness  of  coal  dust  and  the 
power  for  harm  of  the  rock  dust  of  the  gold  mines.  Dr.  F.  I.  Allen,  who  has 
been  for  several  years  Medical  Ofiicer  to  the  leading  Transvaal  collieries, 
states  that  although  anthracosis  is  common  among  coal  miners,  it  does  not 
impair  the  health  nor  the  working  capacity  of  the  men  compared  with  the 
sihcosis  of  the  gold  miner.  This  circumstance  confirms  what  has  already 
been  stated,  that  the  physical  character  of  the  dust  is  an  important  factor  in 
pneumokoniosis.  The  fibrosis  present  in  the  lungs  of  persons  who  have 
worked  in  a  dust  atmosphere  of  itself  suggests  that  we  raise  the  question 
whether  the  fibrosis  is  the  consequence  of  irritation  induced  by  foreign  par- 
ticles inhaled,  or  whether  the  foreign  particles  seen  in  the  lungs  after  death 
have  not  been  caught  and  retained  in  the  lungs  owing  to  those  organs  having 
undergone  a  fibrotic  change  through  the  operation  of  some  other  cause  than 
dust.  For  a  comprehensive  study  of  the  relation  of  pulmonary  fibrosis  and 
dust  Dr.  Shuflflebotham's  Milroy  Lectures  will  repay  perusal.-  This  subject 
is  not  less  interesting  than  is  that  of  pneumokoniosis  and  such  microbic 


DUST   DISEASES    OF    THE    LUNGS  221 

infection  as  tubercle  to  which  we  refer  later.  Dust  of  animal  origin  as 
wool,  hair,  and  feathers  induces  catarrh  of  the  respiratory  passages  rather 
than  structural  changes  in  the  lungs. 

In  pneumokoniosis  so  completely  replaced  is  the  sponge-like  structure 
of  the  lungs  by  sohd  tissue  that  it  is  difficult  to  understand  how  respiration 
is  carried  on  even  as  well  as  it  seems  to  be.  In  some  occupations  more  than 
one  kind  of  dust  is  present  in  the  atmosphere.  This  is  the  case  in  the  Sheffield 
steel  grinders  in  whose  lungs  there  may  be  particles  of  steel  and  also  particles 
of  stone  from  the  grindstone.  Masons  who  chisel  fine  sandstone  are  more 
prone  to  phthisis  than  men  who  chip  and  chisel  granite  where  the  particles  of 
dust  are  heavier.  It  is  owing  to  the  larger  and  heavier  size  of  the  particles 
of  dust  that  the  comparative  freedom  of  the  Aberdeen  granite  worker  from 
phthisis  is  attributed.  A  change  apparently  is  creeping  over  this  industry. 
Since  the  introduction  of  pneumatic  tools  for  cutting  and  smoothing  the 
stone  greater  quantities  of  fine  dust  are  raised,  and  as  the  work  is  carried  on  no 
longer  in  open  sheds  there  has  been  recently  more  lung  trouble  among  the 
granite  workers.  The  lungs  of  men  who  work  in  oxide  of  iron  are  bro^vnish 
red  in  color.  The  structural  changes  in  the  lungs  in  pneumokoniosis  com- 
mence in  the  interstitial  tissue;  subsequently  the  pleura  tends  to  become 
involved.  Emphysema  is  also  present  and  there  are  usually  signs  of  a  wide- 
spread bronchitis. 

The  best  t>^es  of  pneumokoniosis  are  found  in  persons  working  in  such 
dusty  atmospheres  as  those  of  the  Sheffield  trades,  ganister  crushing,  buhr- 
stone  masonry,  and  the  gold  mines  of  South  Africa  and  elsewhere. 

Since,  practically  speaking,  the  same  morbid  changes  are  present  in  all 
forms  of  pneumokoniosis  no  matter  what  the  particular  kind  of  dust  which  has 
caused  the  disease,  it  is  unnecessary  to  describe  in  detail  the  various  forms  of 
pneumokoniosis.  Although  there  is  little  difference  in  the  pathological 
appearances  presented  by  a  lead  miner's  lung,  a  gold  miner's  lung  and  that 
j  of  a  Sheffield  or  other  steel  grinder,  there  is  setting  aside  individual  idiosyn- 
crasy, not  perfect  uniformity  since  in  some  forms  of  pneumokoniosis  there  is 
during  life  a  greater  tendency  to  pulmonary  hemorrhage  than  others. 

Persons  employed  in  dusty  trades  have  a  shorter  life  by  a  few  years  than 
those  employed  in  occupations  free  from  dust.  It  must  not  be  forgotten  that 
to  this  shortening  of  life  other  circumstances  than  dust  contribute.  Buhr- 
stone  is  one  of  the  hardest  stones  known.  It  is  used  for  making  millstones 
i  for  the  grinding  of  cereals,  coprolites,  etc.  It  is  not  a  -large  industry.  I 
I  have  visited  the  buhrstone  yards  on  the  Thames  and  at  Fierte-sous-Jouarre 
in  France.  Few  buhrstone  w^orkmen  live  beyond  the  age  of  35-40.  Most 
of  them  are  intemperate  in  the  use  of  alcohol.  The  men  complain  that,  in 
the  operation  of  chiselling,  the  dust  gets  into  the  back  of  the  throat  and 
creates  an  exasperating  sense  of  dryness  which  stimulants  remove.  At 
Fierte-sous-Jouarre  I  found  men,  comparatively  young,  who  consumed  a 
bottle  of  brandv  dailv  in  addition  to  a  liter  or  more  of  red  wine.     The  men 


222  SYSTEMIC    OCCUPATIONAL    DISEASES 

who  Stood  the  work  best  and  who  exceeded  50  years  of  age  were  abstainers. 
Alcohol  made  the  men  careless. 

Canister  disease  is  a  form  of  silicosis  due  to  inhalation  of  the  dust  of 
ganister,  an  exceedingly  compact,  close-grained  and  highly  siliceous  rock. 
It  contains  99  per  cent,  of  pure  silica.  Owing  to  the  almost  adamantine 
hardness  of  ganister  the  rock  cannot  be  won  by  the  ordinary  methods  of 
mining.  It  has  to  be  blasted.  The  broken  rock  is  placed  in  powerful  grind- 
ing mills  to  be  pulverized  preparatory  to  being  made  into  bricks  which, 
since  they  are  capable  of  resisting  extremely  high  temperatures,  are  used 
for  lining  the  interior  of  iron  blast  furnaces.  The  men  who  mine  the  ganister, 
those  who  grind  it  and  those  who  make  it  into  bricks  all  suffer,  but  in  varying 
proportions,  from  pneumokoniosis.  For  every  1000  men  employed  Dr. 
Birmingham^  found  that  each  year 

42.3  ganister  miners  die  | 

170.8  ganister  grinders  die  } 

.        per  cent. 
22.2  ganister  brickmakers  die  J 

179.8  deaths  per  1000  ganister  grinders  is  an  appallingly  high  mortality 
rate.  The  invasion  of  the  lungs  by  the  dust  is  generally  indicated  by  signs 
of  bronchitis.  As  the  disease  advances  the  lung  becomes  the  seat  of  well- 
marked  fibrosis.  Once  symptoms  reveal  themselves  the  disease  is  found 
fully  developed  within  i  year.  The  miner  becomes  anaemic  and  enfeebled 
and  his  breathing  quickened.  There  are  dyspnoea  on  the  slightest  exertion 
and  hacking  cough.  Few  of  the  patients  survive  2  or  3  years.  Death  is 
generally  due  to  tuberculosis. 

According  to  Dr.  Robertshaw,  Medical  Officer  of  Health,  Stockbridge, 
the  mortality  of  ganister  miners  from  pulmonary  tuberculosis  has  fallen 
15  per  cent,  in  recent  years,  while  the  median  age  at  death  has  risen  from 
37  to  45  years,  owing  to  the  compulsory  use  of  steam  jets  in  the  grinding 
mills. 

According  to  Dr.  Edgar  L.  CoUis,  English  stone  masons  have  a  mor- 
tality rate  three  times  greater  than  that  of  all  occupied  males;  also  while 
the  average  age  at  death  used  to  be  37-38  it  has  in  recent  years  risen  to  43-44. 
Sandstone  is  more  dangerous  than  limestone.  The  mortality  rate  of  stone 
masons  is  not  the  same  for  every  district.  This  Collis  shows  is  largely  due 
to  the  amount  of  silica  present  in  different  kinds  of  stone.  The  dangerous 
ingredient  is  silica.  The  pulmonary  tuberculosis  of  stone  masons  comes  on 
at  a  later  period  of  life  than  in  males  generally,  and  is  only  slightly  infective. 
A  similar  absence  of  the  infectiveness  of  tuberculosis  in  the  Grinskill  quarry- 
men  is  alluded  to  by  Dr.  Wheatley,^  Medical  Officer  of  Health  for  Shrop- 
shire. He  says  that  there  is  no  excess  of  phthisis  in  the  wives  of  men  who 
are  victims  of  the  disease. 

In  the  gold  mines  of  the  Rand  the  men  who  work  rock  drills  driven  by 
compressed  air  are  short  lived.     Five  to  6  years  of  work  bowl  most  of  the 


DUST   DISEASES    OF   THE    LUNGS  223 

men  over.  Silicosis  in  rock  drillers  seldom  develops  until  after  3  years' 
work,  but  once  the  disease  originates,  if  the  men  continue  to  follow  their 
employment,  within  other  2  years  many  of  them  die.  The  men  who  use 
the  hand  drill  are  less  liable  to  be  overcome  by  the  dust  than  those  who  use 
drills  driven  by  compressed  air.  The  work  is  carried  on  at  great  depths. 
Several  of  the  miners  go  down  3000  ft.  and  more.  The  work  is  fatiguing, 
the  ventilation  is  bad,  the  temperature  high  and  the  noise  is  great.  After  a 
day's  work  in  the  mine  the  men  when  perspiring  are  rapidly  transported  by 
means  of  lifts  to  the  surface  where  the  temperature  is  several  degrees  colder 
than  that  in  the  mine.  As  bronchial  catarrh  thus  induced  is  given  little 
heed  to  by  the  miners,  the  way  is  prepared  for  any  dust  which  is  inhaled 
more  readily  to  reach  the  lungs.  In  one  sense  the  men  themselves  are 
partly  responsible  for  the  pulmonary  disease.  After  firing  explosives  in 
the  mine  to  shatter  the  rock  they  return  too  early  to  the  place  of  work  before 
the  fumes  have  cleared  away  and  the  dust  has  had  time  to  settle.  The 
owners  of  the  mines  could  do  more  than  they  have  done  to  improve  the 
ventilation  of  the  South  African  gold  mines.  In  some  of  the  mines  there  is 
a  total  disregard  of  all  hygienic  measures.  Unless  greater  attention  is 
given  to  details  of  hygiene  personal  and  general,  medical  examinations  of 
the  men  before  undertaking  the  work  avails  but  little. 

Prevalence  of  Miners'  Phthisis  in  South  Africa 

In  a  lecture  Dr.  Watkins-Pitchford^  stated  that  in  the  opinion  of  the 
Transvaal  Miners'  Phthisis  Commission  of  1903  probably  21  per  cent,  of  all 
underground  miners  were  affected  with  silicosis.  In  191 2  the  Second  Com- 
mission after  examining  3136  underground  miners  found  990  or  32  per 
cent,  suffering  from  miners'  phthisis  in  one  or  other  of  its  stages,  and  of 
these  about  two-thirds  of  the  cases  were  in  the  stage  of  early  fibrosis.  As 
the  use  of  the  rock  drill  is  regarded  as  the  main  cause  of  the  lung  trouble  it 
is  to  be  noted  that  while  in  December,  1905,  there  were  1800  of  these  machines 
at  work,  in  December,  191 2,  there  were  5600. 

Since  the  gold  mines  of  South  Africa  supply  the  best  illustrations  of 
pneumokoniosis  and  the  largest  number  of  victims  of  the  malady,  and 
since  it  is  from  the  men  who  have  worked  in  these  mines  and  have  returned 
in  ill  health  to  Great  Britain  that  my  ow^n  experience  has  been  drawn,  I 
may  be  pardoned  if  a  further  slight  digression  is  made  into  the  mining  and 
other  conditions  which  prevail  in  the  Transvaal.  Both  white  men  and 
Kafiirs,  called  "boys,"  are  employed.  On  the  Witwatersrand  the  average 
number  of  white  miners  working  underground  in  191 2  was  11,607;  i^  ^^^^ 
year  161  white  miners  died  from  sihcosis.  Notwithstanding  the  fact  that 
many  invalided  miners  came  home  to  the  North  of  England,  Cornwall 
and  elsewhere  the  deaths  from  silicosis  in  the  Transvaal  were  13.8  per  1000 
for  the  year. 


224  SYSTEMIC    OCCUPATIONAL   DISEASES 

The  number  of  natives  working  underground  for  191 2  was  149,782 
out  of  an  available  supply  of  192,522;  of  these  men  153  died  from  silicosis — 
a  small  number  compared  with  the  white  men,  but  possibly  explained  by  the 
fact  that  the  natives  do  not  remain  long  at  work  but  return  to  their  homes. 

When  we  consider  that  on  an  average  there  are  11,840  white  miners 
working  underground  in  the  Rand  and  that  at  least  32  per  cent,  of  these 
are  affected  with  miners'  phthisis  it  is  safe  to  conclude  that  3700  of  these  men 
are  the  victims  of  silicosis. 

Causation  of  Pneumokoniosis  in  General 

Inhalation  of  dust,  hard  and  gritty,  also  sharply  angular  is  the  main 
cause.  In  the  case  of  the  coal  miner  it  is  not  the  carbon  particles  of  the  coal 
but  the  stony  particles  to  which  the  carbon  particles  are  afl&xed  which  injure 
the  lung.  The  pneumokoniosis  of  the  steel  grinder  is  caused  by  inhalation 
of  particles  of  steel  and  sandstone — mostly  the  latter;  the  lung  disease  of  the 
Transvaal  gold  miner  is  the  result  of  inhalation  of  quartzite,  a  siliceous 
sandstone  which  has  become  hardened  and  solidified  by  metamorphosis, 
Interbedded  in  the  quartzite  are  shallow  beds  of  conglomerate  or  "banket" 
composed  of  quartz  pebbles  and  pellets  of  pyrites  cemented  into  a  solid 
mass  by  silica.  The  gold  is  found  in  a  finely  divided  state  in  the  material 
which  binds  the  pebbles  together.  The  main  object  of  the  gold-producing 
industry  of  the  Rand  is  to  mine  the  conglomerate,  bring  it  to  the  surface, 
crush  it  to  powder  and  extract  the  gold  by  the  amalgamative  and  cyanide 
of  mercury  process.  "Silicosis  is  caused  by  the  inhaling  of  the  dust  which 
arises  when  the  conglomerate  as  well  as  the  various  rocks  which  have  been 
mentioned  are  drilled,  blasted,  shovelled  and  crushed."  To  secure  the 
gold-bearing  conglomerate  the  quartzite  has  to  be  broken.  This  is  ac- 
complished by  drilling  holes  4  to  8  ft.  deep  into  the  quartzite  and  placing 
in  the  bottom  of  the  holes  dynamite  cartridges  fitted  with  detonator  and 
fuse.  As  hand  drilling  is  a  slow  process  the  work  is  now  almost  entirely 
done  by  machine  drills,  of  a  percussive  and  not  of  a  rotary  type,  driven  by 
compressed  air.  In  an  8-hours  shift  a  rock-driller  will  bore  through  22 
to  50  ft.  of  solid  rock,  i.e., he  will  bore  from  4  to  8  holes.  In  order  to  lay  the 
dust  generated  during  the  process  of  boring  the  interior  of  the  hole  and  the 
immediate  surroundings  are  kept  wet  with  water  by  spraying.  By  this 
means  the  dust  which  would  otherwise  be  dangerous  is  converted  into  mud. 
Upwardly  inclined  holes  are  with  difficulty  kept  wet.  The  rock  drills  used 
are  principally  the  Ingersoll  and  the  Leyner.  It  is  advantageous  to  use  a 
rock  drill  which  automatically  washes  out  the  hole  with  water  at  the  same 
time  that  it  bores.  The  amount  of  mud  thus  formed  is  considerable.  When 
dried  this  would  again  become  a  source  of  danger  to  the  men.  To  obviate 
this  the  mines  have  to  be  kept  as  damp  as  possible.  The  moisture  of  the 
mine  and  the  high  temperature  in  which  the  men  are  working  are  not  with- 


DUST   DISEASES    OF   THE    LUNGS  22$ 

out  influence  in  causing  fatigue  and  in  reducing  the  vital  resistance  of  the 
workers. 

During  blasting  of  the  rock  considerable  quantities  of  fine  dry  dust  are 
dissipated  through  the  mine.  Shovelling  of  the  detached  rock  and  its 
transference  by  wagon  also  contribute  to  the  dustiness  of  the  atmosphere. 
The  fine  particles  of  dust  remain  suspended  in  the  air  a  long  time;  they  are 
capable  of  passing  through  very  fine  sieves  so  that  after  the  use  of  explosives 
it  is  absolutely  essential  that  the  miners  should  not  return  too  early  to  that 
particular  part  of  the  mine  in  which  they  had  been  working.  According 
to  Mining  Regulations  half  an  hour's  delay  is  considered  to  be  long  enough  if 
the  air  is  free  from  dust,  smoke  and  fume  as  perceived  by  sight  and  smell, 
for  miners  to  return  to  the  working.  Thirty  minutes  is  hardly  long  enough 
for  the  fine  dust  to  settle.  Somehow  or  other  fine  dust  seems  to  take  longer 
to  settle  in  a  mine  than  at  the  surface.  Hitherto  gold  miners,  as  they  are 
paid  according  to  the  number  of  feet  driven  by  drilling  or  sunk  in  develop- 
ment faces,  have  in  their  haste  to  make  large  wages  disregarded  many  of 
the  simple  rules  which  make  for  health. 

Symptomatology. — In  nearly  all  the  South  African  gold  miners  whom  I 
have  treated  for  pulmonary  disease  the  malady  has  bten  in  existence  for 
several  months.  Once  it  is  developed  the  disease  may  last  2  years  or  more. 
There  are  cases  on  record  of  "acute  pulmonary  silicosis"  where  after  a  sharp 
attack  of  broncho-pneumonia  the  patient  who  had  worked  only  a  few  months 
dies.  After  death  the  lungs  are  found  to  be  congested,  oedematous  and 
irregularly  pigmented  without  the  naked-eye  appearance  of  fibrosis.  On 
microscopical  examination  of  sections  of  the  lungs  by  polarized  light,  in  the 
connective  tissue  are  seen  myriads  of  siliceous  particles.  The  pulmonary 
alveoli  are  filled  with  catarrhal  cells  and  serous  exudate.  It  is  unusual  for 
miners  to  die  so  early.  The  silicosis  for  which  miners  seek  advice  develops 
slowly,  so  insidiously  in  fact  that  it  is  difficult  for  the  patient  to  assign  a 
date  to  the  onset  of  symptoms  of  which  dry  cough  in  the  morning  or  on 
leaving  the  mine  at  the  end  of  the  day  is  one  of  the  earliest  symptoms. 
What  appears  to  be  a  bronchial  cold,  with  or  without  pleuritic  pains,  at- 
tended by  a  sense  of  increasing  debility  is  an  indication  that  the  lung  has 
become  affected  by  mine  dust.  One  feature  stands  out  prominently  through- 
out the  whole  course  of  gold  miners'  phthisis,  viz.,  dyspnoea  on  the  slightest 
exertion — a  shortness  of  breath  far  in  excess  of  physical  signs.  The  general 
appearance  of  the  affected  miner  is  that  of  a  man  still  in  health.  He  is 
frequently  slightly  bronzed  and  looks  weather-beaten,  and  yet  the  disease 
may  already  have  got  a  good  grip  of  his  lungs  for  on  physical  examination 
the  chest  is  observed  to  expand  feebly,  there  is  a  diminution  of  i  in,  or 
more  in  the  ratio  between  inspiratory  and  expiratory  measurements,  also 
impairment  of  the  percussive  note  at  the  base  of  the  lung  toward  the  axillary 
area  with  deficient  respiratory  murmur.  The  pulse  is  almost  invariably 
quickened.  In  the  later  stages  the  respiratory  murmur  may  become  coarser, 
IS 


2  26  SYSTEMIC    OCCUPATIONAL    DISEASES 

crepitation  may  be  heard,  also  a  cardio-respiratory  murmur  along  the  left 
border  of  the  cardiac  area.  The  expectoration  varies.  In  the  early  stages 
if  there  is  little  bronchial  catarrh  expectoration  may  be  scanty,  stringy  and 
pearly  white  in  character;  in  the  later  stages  it  may  be  mucopurulent,  bluish 
black  and  rich  in  particles  of  silica.  In  the  last  stage  of  the  disease  it  fre- 
quently contains  tubercle  bacilli.  As  the  disease  proceeds  the  tendency  is 
for  the  expansive  power  of  the  chest  still  further  to  diminish  in  consequence 
of  pleuritic  adhesion  and  an  increasing  loss  of  elasticity  of  the  lung  due  to 
extension  of  the  fibrosis.  Although  gold  miners'  phthisis  is  of  slow  de- 
velopment, men  have  died  suddenly  from  cardiac  failure  when  at  work 
in  the  mine.  In  only  a  few  of  the  patients  is  hemoptysis  a  symptom.  The 
thoracic  organs  are  those  which  alone  suffer.  Those  of  the  abdomen  re- 
main healthy;  the  urine  is  free  from  albumen.  In  the  hands  of  some  medical 
men  the  application  of  the  Rontgen  rays  for  illuminating  the  chest  has 
been  of  service  in  showing  the  extent  to  which  the  lungs  are  infiltrated  with 
dust. 

Prognosis. — The  prognosis  is  good  only  in  the  early  stages,  provided  the 
patient  gives  up  work  and  takes  to  a  life  in  the  open.  Once  tubercle  bacilli 
have  settled  in  the  lung  the  patient  goes  rapidly  down  hill.  Almost  similar 
symptoms  are  observed  in  workers  in  other  dusty  trades.  In  some,  bronchial 
symptoms  predominate.  Potters,  for  example,  have  been  known  to  exhibit 
a  high  mortality  rate  from  lung  diseases.  Potter's  rot  or  asthma  was  de- 
scribed by  Arlidge  and  attributed  by  him  to  the  inhalation  of  fine  flint  dust 
which  is,  practically  speaking,  pure  silica.  The  symtpoms  are  morning  cough 
and  shortness  of  breath  with  unimpaired  general  health;  later  the  cough  be- 
comes paroxysmal  and  is  attended  by  a  degree  of  dyspnoea  in  excess  of  that 
observed  in  phthisis.  Blood  spitting  is  unusual.  On  physical  examination 
of  the  chest  there  are  patches  of  dulness  detected  at  the  bases  and  signs  of 
empyema  in  the  front  of  the  chest.  Owing  to  the  strain  imposed  upon  the 
right  side  of  the  heart  this  organ  dilates.  The  malady  at  first  is  non-tuber- 
culous, but  as  time  goes  on  the  lungs  may  become  infected  by  Koch's  bacillus. 

Metal  grinders  are  especially  exposed  to  the  risk  of  pulmonary  disease 
owing  to  the  hard  and  angular  form  of  the  dust  inhaled.  Sanfield  speaking 
of  Sheffield  steel  grinders  points  out  that  they  have  a  mortality  rate  from 
pulmonary  phthisis  three  times  greater  than  that  of  cutlers.  The  disease 
assumes  the  form  of  fibrosis  and  is  attended  by  diminished  expansion  of  the 
chest.  In  all  of  us  as  age  advances  the  power  of  expansion  of  the  chest 
diminishes.  At  the  age  period  45-49  years  the  normal  individual  expires 
419  cc.  of  air  less  than  he  did  at  the  age  period  20-24,  but  A.  E.  Barnes  of 
Sheffield  states  that  the  cutler  expires  732  cc.  less  and  the  steel  grinder  751 
cc.  less.  ColHs  found  a  high  blood  pressure  run  concurrently  with  diminished 
chest  expansion. 

The  Transvaal  Chamber  of  Mines^  has  published  in  its  Reports  certain 
schedules  of  the  Miners'  Phthisis  Board.     In  one  of  these  the  expectation  of 


DUST   DISEASES    OF    THE    LUNGS 


227 


life  based  upon  the  permanently  impaired  physical  capacity  of  the  men  for 
underground  work  is  compared  with  the  normal  expectation  of  life  of  men  of 
the  same  age  calculated  according  to  the  Carlisle  tables.  The  conclusion 
drawn  is  that  whereas  a  person  of  the  age  of  42%  years  should  have  on  an 
average  of  26  years  to  live,  a  person  of  the  same  age  who  has  worked  under- 
ground in  the  mines  g}'^  years  would  have  an  expectation  of  only  ij^^  years. 
The  following  figures,  taken  at  random,  for  200  cases  of  beneficiary  miners 
supplied  by  the  Miners'  Phthisis  Board  for  6  months  ending  January 
31,  1913,  are  not  without  interest  even  if  they  have  not  met  with  general 
acceptance. 


Actual  service 
underground 

Average  actual  ser- 
vice underground, 
years 

Average  age  of 

miners  in  each  class, 

years 

Normal  expecta- 
tion of  life,  Carlisle 
tables,  years 

Medical  advisers' 
certificate  of  ex- 
pectation of  life 
average,  years 

8  years  or  over 
7  to  8  years. .  . 
6  to  7  years. .  . 
5  to  6  years. .  . 
4  to  5  years. .  . 
2  to  4  years. .  . 

9>i 
3 

42% 

36 

34 

26 

31 
28 

30 

27 

31 

2^ 

3 

Of  the  miners  who  applied  for  compensation  under  the  Miners'  Phthisis 
Act,  191 2,  and  have  since  died  but  were  examined  by  the  Medical  Advisers 
to  the  Board  before  death,  the  number  of  deaths  was  39:  The  Medical 
Advisers'  average  expectation  of  the  applicants'  life  was  7%  months,  instead 
their  actual  average  Hfe  was  only  1^:5  months. 

Pathology. — Irrespective  of  the  particular  kind  of  dust  which  has  led 
to  the  development  of  pneumokoniosis,  one  and  the  same  structural  change 
is  invariably  present  in  all  affected  lungs,  if  only  sufficient  time  is 
given.  I  refer  to  an  increase  of  the  fibro-connective  tissue  of  the  organs, 
an  interstitial  pneumonia  in  fact,  accompanied  by  the  presence  of  pigment 
without  recognizable  evidence  of  tubercle  or  syphilis.  The  fibrous  tissue 
tends  to  assume  in  places  concentric  formation,  the  fibrosis  being  particularly 
well  marked  around  blood-vessels  and  small  bronchi.  It  is  around  these  that 
the  earliest  changes  are  detected.  The  blood-vessels  become  thickened  as 
a  result  of  endarteritis  or  in  consequence  of  prolonged  venous  congestion. 
There  are  usually  signs  of  bronchial  catarrh.  On  microscopical  examination 
particles  of  dust  can  be  seen  imbedded  in  large  endothelial  cells  lying  inside 
the  alveoli  and  also  in  the  fibroblasts.  Occasionally  free  red  blood  cells  can 
be  seen  occupying  the  alveoli  as  a  consequence  of  venous  congestion  or  more 
probably  as  a  consequence  of  hemorrhage  from  newly  developed  thin-walled 
vessels  such  as  occur  in  granulative  tissue.  The  development  of  new  blood- 
vessels is  an  interesting  feature  in  pneumokonioses,  for  while  at  first  they  are 
capable  of  meeting  all  nutritive  demands  the  blood  supply  ultimately  be- 
comes restricted,  a  condition  which  may  lead  to  necrosis. 


2  28  SYSTEMIC    OCCUPATIONAL   DISEASES 

This  brief  statement  requires  a  further  and  more  carefully  detailed  account 
of  the  microscopical  appearance  of  sections  of  a  lung  in  pneumokonioses,  and 
as  the  structural  changes  are  particularly  well  marked  in  a  non-tuberculous 
fibrotic  lung,  which  was  sent  to  me  by  Dr.  Aitken  of  the  Miners'  Sanitarium, 
South  Africa,  I  will  make  these  the  basis  of  my  remarks.  For  assistance  in 
the  description  of  the  pathological  changes  I  am  indebted  to  my  colleague. 
Prof.  Stuart  McDonald.  When  animals  have  been  exposed  interruptedly 
to  a  dusty  atmosphere  over  a  considerable  length  of  time  one  of  the  earliest 
signs  in  the  lungs  is  the  presence  of  large  pigmented  cells  lying  free  within 
the  alveoli.  These  cells  are  phagocytes.  Some  of  the  cells  may  be  extended 
leucocytes,  others  are  modified  alveolar  endothehal  cells.  During  the  act 
of  coughing  some  of  these  pigmented  cells  as  well  as  others  lying  on  the  bron- 
chial mucous  membrane  are  expelled  and  can  be  found  in  the  expectoration. 
In  another  way  the  fate  of  these  dust  alveoh  is  interesting.  Many  of  them 
penetrate  through  the  stomata,  they  break  through  between  the  alveolar 
epithelium  into  the  lymphatics  of  the  fibro-connective  tissue  framework 
of  the  lung  and  are  carried  to  the  glands  at  the  hilus  or  they  disintegrate 
and  induce  an  irritative  fibrous  hyperplasia.  Irritation  by  this  foreign 
material  is  capable  alone  of  inducing  the  fibrous  overgrowth  observed  in 
typical  silicotic  nodules,  but  probably  other  factors  are  in  operation  as  well. 
Many  of  the  smaller  bronchioles  have  their  lumen  blocked  by  catarrhal 
products  and  by  oedema  attended  by  collapse  of  the  immediate  lung  tissue. 
Where  collapse  has  occurred,  the  alveolar  walls  become  thickened  and  there 
develops  an  area  of  fibrous  tissue  which  is,  practically  speaking,  free  from  dust 
particles.  Here  and  there  may  be  seen  small  areas  of  lung,  seats  of  acute 
pneumonic  consolidation.  The  intra-alveolar  exudate  varies.  It  may  be 
composed  of  mononuclear  ceUs  which  have  come  from  a  proliferating  alveolar 
endothehum,  or  it  may  be  fibrinous  in  character  and  include  numerous  leuco- 
cytes within  its  meshes.  Numerous  free  red  blood  cells  are  seen  inside  the 
alveoli  and  in  irregular  situations.  The  presence  of  newly  formed  capillaries 
in  the  exudate  points  to  a  fibrous  organization  taking  place  such  as  is  oc- 
casionally seen  in  an  unresolved  pneumonia.  As  regards  the  source  of  the 
newly  formed  fibrous  tissue  it  may  be  that  some  of  the  larger  mononuclear 
cells  and  also  some  of  the  smaller  cells  of  the  lymphocyte  type  play  a  part. 
The  bulk  of  it  is  the  product  of  fibroblastic  cells,  which,  spindle-shaped, 
flattened  or  branch-like,  can  be  seen  at  the  periphery  of  a  densely  fibrotic 
silicotic  nodule  while  the  smaller  lymphocyte  cells  are  situated  more  e.x- 
tcrnally.  The  fibroblasts  are  also  phagocytic  for  several  of  them  can  be 
seen  ladened  with  foreign  particles.  Branches  of  the  pulmonary  artery  show 
fibrous  and  elastic  thickening  of  their  inner  coat.  This  is  not  so  apparent  in 
the  finer  divisions  of  the  pulmonary  vein.  The  alveolar  capillaries  are  over- 
filled in  places  and  antemortem  thrombosis  of  the  smaller  blood-vessels  is 
here  and  there  apparent.  Scattered  through  the  lung  are  dense  silicotic 
nodules.     Most  of  these  are  avascular  but  where  the  morbid  change  is  still 


DUST   DISEASES    OF    THE    LUNGS  229 

progressing  the  tissue  is  distinctly  vascular.  In  none  of  the  sections  neither 
to  the  naked  eye  nor  on  microscopical  examination  is  there  the  slightest  evi- 
dence of  tubercle.  Where  the  changes  have  become  most  marked  all  traces 
of  alveolar  structure  have  disappeared;  the  outline  of  thickened  and  obliter- 
ated vessels  may  still  be  traced  amid  accumulations  of  dust  particles,  while  as 
regards  connective-tissue  corpuscles  these  are  represented  by  little  else  than 
free  nuclei.  The  absence  of  pus  cells  is  a  notable  feature.  The  presence  of 
pus  corpuscles  is  usually  a  sign  that  tubercle  has  become  grafted  upon  a  lesion 
which  was  primarily  non-tuberculous.  In  a  large  percentage  of  the  cases, 
probably  70,  death  comes  by  secondary  tuberculosis.  On  careful  examination 
of  the  structureless  material  of  fibrotic  tissue  and  amid  mineral  particles 
tubercle  bacilli  may  be  found,  but  if  present  they  are  few  in  number  and 
are  without  their  usual  histological  accompaniment,  giant  cells. 

In  the  lung  of  a  dog,  the  subject  of  experimental  anthracosis,  I  was  sur- 
prised at  the  large  size  of  the  particles  of  coal  dust  found  in  the  pulmonary 
alveoli  after  death.  The  transport  of  dust  into  the  lungs  during  inspiration 
is  a  fact  beyond  controversy — notwithstanding  all  that  has  been  written 
upon  the  subject  of  tidal  air  in  respiration  and  the  renewal  of  the  air  in  the 
small  bronchi  and  pulmonary  alveoli  by  diffusion.  During  inspiration  when 
men  are  working  hard  a  portion  of  the  tidal  air  must  be  drawn  into  the 
pulmonary  alveoli. 

Silicosis  and  Tuberculosis. — Since  in  a  considerable  number  of  persons 
dying  from  silicosis  no  sign  of  tubercle  is  found  in  the  lungs  or  in  the  body 
generally,  silicosis  must  therefore  in  its  early  stages  at  least  be  regarded  as  a 
non-tuberculous  disease.  In  some  of  my  own  patients  the  malady  from  first 
to  last  was  non-tuberculous.  When  tuberculosis  develops  not  only  is  it 
secondary  to  pneumokoniosis  but  there  occurs  an  alteration  in  the  symptoms. 
Pneumokoniosis  is  of  gradual  development;  it  usually  pursues  its  cause  with- 
out any  pronounced  rise  of  temperature.  Once  tubercle  has  been  grafted 
upon  the  malady,  emaciation  becomes  progressive,  the  temperature  rises, 
there  are  night  sweats,  the  expectoration  becomes  mucopurulent  and  fre- 
quently contains  Koch's  bacillus.  Experience  confirms  the  opinion  based 
upon  experimentally  produced  dust  diseases  of  the  lungs,  viz.,  that  a  patient 
suffering  from  pneumokoniosis  is  more  prone  to  develop  tuberculosis  than  a 
person  otherwise  healthy.  It  might  appear  as  if  the  avascular  state  of  the 
fibrotic  areas  of  an  affected  lung  did  not  lend  itself  to  the  reception  and  mul- 
tiplication of  the  tubercle  bacillus,  but  a  suitable  nidus  is  certainly  provided 
in  the  catarrhal  secretion  within  the  pulmonary  alveoli.  That  dust  diseases 
of  the  lung  specially  predispose  to  other  microbic  diseases  such  as  pneumonia 
is  the  experience  of  medical  men  on  the  Rand.  The  Kaffirs  employed  in  the 
gold  mines  round  Johannesburg  have  an  extremely  high  death  rate  from 
pneumonia.  Not  only  do  the  native  miners  take  the  disease  readily,  but  their 
resistance  to  it  is  diminished. 

The  South  African  Miners'  Phthisis  Commission  of  191 2  reported  that 


230  SYSTEMIC    OCCUPATIONAL   DISEASES 

silicotic  lungs  become  increasingly  liable  to  infection  as  the  fibrosis  pro- 
gresses. Of  the  patients  in  the  early  stage  of  the  disease  6  per  cent,  were 
found  to  be  tuberculous;  of  those  in  the  middle  stage  12  per  cent,  and  in  the 
later  stages  44  per  cent. 

Dr.  G.  A.  Turner  of  Johannesburg  and  Dr.  D.  Macaulay  have  drawn  atten- 
tion to  a  form  of  tuberuclosis  affecting  the  spleen  and  mesenteric  gland, 
found  in  gold  miners.  Not  only  is  the  spleen  studded  with  nodules,  but  in  the 
glands  there  is  observed  proliferation  of  the  proper  elements  with  fibrosis, 
and  signs  of  tubercle  bacilli  are  present  in  small  numbers  and  are  with 
difficulty  detected.  As  indicating  the  types  of  tuberculosis  found  in  the 
Kaffirs  employed  in  the  gold  mines,  Dr.  Turner  reports  that  of  309  deaths 
which  occurred  in  one  of  the  Compound  Hospitals  during  the  6  years  1908- 
1913  and  which  were  confirmed  by  post-mortem  examination,  140  were 
pulmonary,  92  were  cases  of  generalized  tuberculosis,  33  peritoneal,  33 
splenic,  7  hepatic,  3  meningeal  and  i  renal.  Dr.  G.  D.  Maynard^  also 
found  tuberculous  abdominal  lesions  prevalent  in  native  miners  and  is 
therefore  disposed  to  admit  the  possibility  of  infection  having  occurred 
through  the  alimentary  canal.  When  we  remember  that  in  the  mines  the 
expectoration  of  the  men  who  are  the  subjects  of  the  malady  is  widely  dis- 
tributed and  is  found  on  the  walls,  floors,  steps,  hand  rails  of  ladders,  on  the 
inside  of  cages,  also  that  the  native  miners  eat  their  food  with  unwashed 
hands,  infection  by  the  alimentary  canal  is  more  than  a  possibility.  These 
remarks  raise  the  question  as  to  what  is  the  mode  of  entrance  of  dust  into 
the  lungs? 

Mode  of  Entrance  of  Dust  into  the  Lungs 

Is  pulmonary  anthracosis  of  aerial  or  intestinal  origin?  Where  men  had 
been  working  in  a  dusty  atmosphere  and  their  lungs  after  death  are  found 
to  be  deeply  pigmented  it  is  natural  to  suppose  that  the  altered  condition 
of  the  lungs  is  the  result  of  particles  of  dust  which  had  been  inhaled  when 
at  work.  Physical  and  chemical  confirmation  of  the  identity  of  the  dust 
found  in  the  lungs  with  that  present  in  the  atmosphere  of  the  workshop 
lends  weight  to  this  supposition.  Calmette  of  Lille,  Van  Steenberghe  and 
Grysez  in  their  researches  upon  tubercle  concluded  that  tuberculous  lesions 
of  the  lungs  are  not  so  much  the  consequences  of  aerial  infection  by  Koch's 
bacillus  as  that  the  microorganism  enters  the  body  by  the  alimentary  canal 
and  finally  reaches  the  lungs  by  the  lymphatics.  If,  as  these  pathologists 
maintain,  this  is  the  channel  of  infection  by  tubercle  bacilli,  so  in  all  probability 
is  it  the  portal  of  entry  of  the  particles  of  carbon  which  cause  the  anthracosis 
of  coal  miners.  In  their  experiments  they  found  that  the  ultimate  destination 
of  pigment  was  greatly  influenced  by  the  age  of  the  animal  experimented  upon. 
In  the  lungs  of  young  guinea-pigs  particles  of  carbon  were  not  found,  but  they 
were  present  in  the  lungs  of  older  animals,  the  opinion  being  that  while  carbon 
dust  was  arrested  in  the  mesenteric  and  other  abdominal  glands  of  younger 


DUST   DISEASES    OF    THE    LUNGS  23 1 

animals  the  more  open  meshes  of  the  glandular  structure  in  older  animals  per- 
mitted the  passage  of  the  particles  through  the  glands,  and  thus  allowed  of 
their  transport  by  the  lymphatics  to  the  lungs.  I  have  carried  out  several 
experiments  bearing  upon  the  artificial  production  of  anthracosis  both  by  the 
intestinal  canal  and  the  respiratory  passages.  My  own  experience  is  that 
while  pigmentation  of  the  lung  can  be  produced  by  materials  carried  into  the 
intestinal  canal,  there  is  no  comparison  between  this  as  the  portal  of  entry  and 
respiratory  passages.  The  presence  of  particles  of  carbon  lying  free  within  the 
the  pulmonary  alveoli  and  their  presence  too  in  large  phagocytic  cells  lying 
loose  in  the  alveoli  indicate  that  these  particles  must  have  reached  the  lung 
by  the  air  channels.  The  absence  of  pigment  in  the  lungs  of  animals  whose 
esophagus  had  been  ligatured  and  which  had  breathed  air  in  which  particles  of 
soot  were  freely  suspended  is  admittedly  strong  evidence  in  support  of  the 
intestinal  mode  of  entrance  as  advanced  by  Calmette  and  his  school,  so  too 
his  other  experiment  where  pigment  was  found  in  the  lungs  when  the  esoph- 
agus was  open  but  one  of  the  bronchi  ligatured.  In  Great  Britain  Pro- 
fessor Whitla  of  Belfast  is  one  of  the  strongest  adherents  of  the  intestinal 
origin  of  anthracosis.  His  conclusions  rest  upon  data  obtained  by  repeating 
Calmette's  experiments  and  especially  those  of  the  introduction  of  Indian 
ink  by  the  intraperitoneal  method.  In  my  own  intraperitoneal  experiments 
I  have  been  impressed  by  the  rapidity  with  which  even  considerable  particles 
of  coal  dust  were  transported  to  the  abdominal  glands,  including  such  organs 
as  the  testes.  The  peritoneal  cavity  is  a  large  lymphatic  space  from  which 
infective  material  is  rapidly  absorbed  and  conveyed  by  the  lymphatics,  but 
although  such  material  may  finally  reach  the  lungs  it  never  reaches  them  in 
such  quantity  as  when  aspirated  into  the  lungs  by  breathing.  Supporters 
of  the  theory  of  the  intestinal  origin  of  pulmonary  anthracosis  lay  stress  upon 
the  mechanical  obstacles  such  as  the  presence  of  ciliated  epithelium  in  the 
upper  portions  of  the  respiratory  canal,  the  branching  and  narrowing  of  the 
bronchial  tubes  which  render  it  difficult  for  dust  to  reach  the  lungs.  The 
abdominal  glands  of  coal  miners  are  occasionally  black  but  never  in  compari- 
son with  the  bronchial  glands  or  the  lungs.  In  the  alveoli  of  the  lungs  of 
rabbits  and  dogs  exposed  for  i  hour  daily  to  an  atmosphere  rendered  .dusty 
by  means  of  finely  powdered  coal  there  can  be  seen  numerous  large  cells  of 
the  epithelioid  type  which  have  engulfed  fine  particles  of  dust.  These 
cells  are  phagocytes.  They  are  expelled  in  the  expectoration  or  they  may 
penetrate  through  the  alveolar  endothelium  and  reach  the  connective- 
tissue  framework  of  the  lungs  or  the  lymphatics.  They  are  carried  by  the 
lymphatics  to  the  bronchial  glands  where  they  unburden  themselves  of  the 
pigment  they  have  brought  or  they  undergo  disintegration  dispersing  the 
pigment  as  fine  dust.  Instead  of  using  particles  of  soot  or  of  Indian  ink,  iron 
carbonate  can  be  administered  and  its  presence  subsequently  demonstrated 
by  a  blue  color  obtained  with  hydrochloric  acid  and  ferrocyanide  of  potas- 
sium.    Dr.  Leonard  Findlay^  repeated  Calmette's  experiments  and  he  found 


232  SYSTEMIC   OCCUPATIONAL  DISEASES 

that  where  animals  were  fed  for  days  with  emulsions  of  soot  or  Indian  ink 
through  a  stomach  tube  the  lungs  showed  no  abnormal  pigmentation,  that 
when  fed  with  iron  carbonate  by  the  stomach  tube  for  27  days,  while  large 
quantities  of  iron  carbonate  were  present  in  the  mesenteric  glands,  the 
lungs,  with  the  exception  of  a  small  patch  of  broncho-pneumonia,  were  free 
from  iron  carbonate  although  particles  of  soot  were  present  in  the  epithehal 
cells  of  the  alveoli.  Where  animals  breathed  an  atmosphere  ladened  with 
soot,  the  esophagus  and  both  of  the  bronchi  at  the  time  being  free,  the 
lungs  were  found  invariably  pigmented;  in  the  case  of  other  animals  breathing 
a  similar  atmosphere  but  whose  esophagus  had  been  ligatured  the  lungs  were 
pigmented  and  the  alveolar  cells  contained  carbon,  but  the  mesenteric  glands 
were  free  from  soot.  Finlay  caused  a  tracheotomized  animal  to  breathe  a 
soot-ladened  atmosphere,  its  left  bronchus  being  plugged  with  cotton  wool. 
The  animal  inhaled  dust  for  2  hours.  When  killed  the  right  lung  was  of  dark 
color  while  the  left  still  retained  the  rosy  appearance  of  health.  In  the 
alveoli  of  the  right  lung  were  found  considerable  amounts  of  pigment. 
Where  animals  breathed  for  varying  periods  iron  carbonate,  their  esophagus 
and  bronchi  free,  the  alveolar  cells  gave  the  Prussian  blue  reaction  with 
potassium  ferrocyanide.  After  intraperitoneal  injections  of  soot,  also  of 
Indian  ink,  the  lungs  were  usually  entirely  free  from  pigment  while  the 
mesenteric  glands  were  pigmented.  In  a  few  instances  the  mediastinal  glands 
were  pigmented  and  the  lymphatics  of  the  lungs  which  run  in  the  alveolar 
walls  contained  the  colored  material.  It  is  difficult  to  produce  pulmonary 
anthracosis  by  feeding.  The  difference  in  the  pigmentation  of  lung  caused 
by  the  inhalation  of  foreign  particles  and  the  same  when  introduced  by  the 
alimentary  canal  is  that  when  dust  has  been  inhaled  the  dust  particles  are 
found  lying  inside  the  pulmonary  alveoli,  whereas  when  introduced  by  the 
intestinal  canal  if  they  reach  the  lung  at  all  they  are  found  lying  in  the 
interior  of  the  lymphatics.  My  own  opinion  in  regard  to  the  origin  of 
pulmonary  anthracosis  is  that  while  the  dust  may  reach  the  lungs  by  both 
the  intestinal  ahd  respiratory  passages  the  latter  is  the  more  frequent  of  the 
two. 

Prof.  Beattie  of  Liverpool  University  has  been  extremely  successful  in 
producing  the  early  stages  of  pneumokoniosis  in  guinea-pigs  by  causing  them 
to  breathe  a  dusty  atmosphere.  Sections  of  the  affected  lungs  show  the 
thickened  alveolar  walls  due  to  proliferation  of  fibro-connective  tissue,  the 
presence  of  pigment  in  the  pulmonary  lymphatics  also,  in  the  large  phagocytic 
cells  lying  within  the  pulmonary  alveoli.  His  experiments  prove  that 
prolonged  inhalation  of  dust  is  capable  of  producing  structural  alterations 
similar  to  those  found  in  the  lungs  of  miners  dying  from  uncomplicated 
pneumokoniosis. 

Treatment. — If  pneumokoniosis  cannot  be  entirely  abolished,  it  certainly 
can  be  largely  prevented.  It  is  a  matter  of  getting  rid  of  the  dust  to  which 
men  are  exposed  when  at  work,  whether  in  the  factory,  grinding  shed,  quarry 


DUST   DISEASES    OF    THE    LUNGS  233 

or  mine.  The  improved  conditions  under  which  coal  miners  work,  their 
better  housing,  shorter  hours  and  higher  wages,  but  above  all  the  freer 
ventilation  of  coal  mines  by  larger  fans  and  by  double  shafts  for  "intake" 
and  "outgo"  air,  have  considerably  reduced  the  mortality  rate  of  miners' 
phthisis.  Ventilation  of  coal  mines,  however,  has  its  limits.  There  is  just 
the  risk  of  excessive  ventilation  sweeping  away  from  the  walls,  floors,  roofs 
and  props  and  carrying  forward  through  a  mine  the  extremely  fine  dust 
which  lies  in  the  mainways.  This  fine  dust  is  not  only  a  menace  to  the  health 
of  the  miners  but  a  cause  of  explosion  in  coal  mines.  Spraying  with  water 
has,  therefore,  been  resorted  to,  but  coal  dust  and  water  do  not  mix  together 
readily.  Coal  dust  floats  in  water  and  is  not  quickly  permeated  by  it ;  besides 
coal  dust  which  has  been  wetted  with  water  on  becoming  dry  is  found  to  have 
undergone  further  disintegration  and  to  have  become  a  finer  form  of  dust. 
Soap-and- water  spraying  and  spraying  by  other  fluids  have  been  recom- 
mended since  they  bind  the  dust  and  render  it  difficult  for  currents  of  air  to 
lift  it.  Herman  Belger  of  the  Armstrong  College,  Newcastle-upon-Tyne, 
has  for  the  last  2  years  carried  out  in  my  laboratory  at  the  College  of  Medicine 
a  series  of  experiments  as  to  how  to  bind  the  dust  so  that  it  will  remain  bound 
under  all  conditions  of  temperature  and  dryness  of  the  atmosphere.  His 
solution  possesses  the  property  of  abstracting  moisture  from  the  atmosphere 
so  that  a  dusty  surface  treated  by  it  remains  more  or  less  moist  and  therefore 
attractive  to  fresh  dust.  Belger's  solution  is  a  colloid  and  contains  calcium 
and  other  salts.  The  colloid  solution  is  harmless  from  a  health  point  of 
view ;  it  has  no  injurious  influence  upon  the  plant  of  a  mine  or  upon  the  seam 
of  coal  rock  or  ore.  Spraying  of  the  interior  of  coal  mines  by  Belger's  solu- 
tion has  been  tried  over  several  miles  of  roadway  in  coal  mines  with  great 
success.  The  colloid  solution  not  only  renders  a  mine  free  from  dust  but 
keeps  it  free.  Wherever  it  has  been  sprayed  there  is  created  a  coolness  in 
the  underground  passages  which  makes  the  work  of  the  miner  easier,  and  at 
the  same  time  it  diminishes  the  risk  of  explosion. 

There  are  dusty  occupations  in  which  men  can  work  wearing  a  respirator. 
Inhalation  of  dust  is  thereby  to  a  great  extent  diminished,  but  where  the  work 
is  hard  and  of  a  laborious  nature  men  complain  that  they  cannot  wear  a 
respirator.  Theoretically  the  wearing  of  a  respirator  is  all  right,  but  it  creates 
heat  and  the  men  cannot  breathe  freely  through  the  respirator. 

Of  the  curative  treatment  of  pneumokoniosis  little  can  be  said.  It  is 
only  in  the  early  stages  that  satisfactory  results  can  be  obtained,  and  that  is 
by  the  men  on  the  first  approach  of  symptoms  retiring  from  the  work  and 
taking  up  occupations  in  the  open  air.  I  know  of  no  specific  medicinal 
treatment  for  pneumokoniosis.  Once  fibrosis  has  begun  there  is  always  the 
probability  of  it  progressing.  If,  however,  the  patient  can  be  kept  free  from 
the  possibiHty  of  tuberculous  infection  he  may  live  for  years,  provided  he  is 
careful  in  his  habits  and  avoids  catching  cold.  By  the  administration  of 
calcium  salts  such  as  chloride  combined  with  a  tonic  like  nux  vomica,  good 


234  SYSTEMIC    OCCUPATIONAL   DISEASES 

food,  abstinence  from  alcohol  and  by  living  in  the  open  air'health  can  be  well 
maintained  and  a  comparatively  useful  life  spent.  Once  tubercle  bacilli 
invade  the  lung  the  patient  rapidly  becomes  worse  and  the  case  practically 
becomes  hopeless.  Silicosis  and  tuberculosis  are  mutually  destructive  to 
each  other.  A  silicotic  lung  soon  breaks  up  in  the  presence  of  tubercle 
bacilli. 

On  the  question  of  the  treatment  of  silicosis  it  would  be  well  to  read  what 
Dr.  Francis  Aitken^  has  to  say,  since  he  has  had  experience  which  falls  to 
few  physicians.  In  November,  191 1,  there  was  opened  at  Modderfontein, 
South  Africa,  a  sanatorium  for  the  treatment  of  miners'  phthisis.  Dr. 
Aitken,  Medical  Superintendent,  states  that  since  the  opening  of  the  sana- 
torium, the  end  of  December,  1913,  there  have  been  admitted  322  cases. 
Miners  in  all  stages  of  the  disease,  with  or  without  tuberculosis,  have  been 
received.  Forty  per  cent,  of  the  men  admitted  were  tuberculous  and  had  to  be 
segregated  from  the  other  inmates.  During  1913,  156  patients  entered  the 
sanatorium;  103  were  discharged  and  48  died.  In  regard  to  the  curability 
of  siUeosis  the  Medical  Superintendent  expresses  himself  thus:  "  Recent 
researches  in  the  pathology  of  the  disease  reveal  the  important  fact  that  the 
fibrous  tissue  which  is  formed  as  a  result  of  the  irritation  by  the  dust  in  the 
lungs,  and  which  is  responsible  for  the  hardening  of  the  lungs  and  their 
impairment  as  respiratory  organs,  tends  in  time  to  become  organized  and 
permeated  by  newly  formed  blood-vessels.  As  a  result,  the  fibrous  tissue  is 
in  part  absorbed  and  the  particles  of  silica  are  liberated  and  carried  away  in 
the  blood  stream.  This  process  makes  for  a  good  prognosis  in  cases  which 
(i)  are  no  longer  exposed  to  a  dusty  atmosphere,  (2)  are  free  from  tuberculosis, 
(3)  have  no  breaking  down  of  the  lungs,  (4)  are  able  to  survive  the  period  of 
heart  strain  that  always  accompanies  any  marked  degree  of  silicosis.  Thus 
it  would  appear  that  early  cases  of  silicosis  that  are  able  to  fulfil  these  condi- 
tions should  be  regarded  as  curable  and  more  advanced  cases  should  improve 
to  a  marked  extent."  Without  comment,  I  close  this  paper  with  the  above 
expression  of  optimism  on  the  part  of  Dr.  Aitken. 

REFERENCES 

^  The  Relation  between  Anthracosis  and  Pulmonary  Tuberculosis,  J.  W.  Wainwright  and 
H.  I.  Nichols.     The  American  Journal  of  the  Medical  Sciences,  Sept.,  1905,  page  403. 
2  British  Medical  Journal,  March  14,   1914. 
"  Journal  of  the  Sanitary  Institute,  Apr.,  1900,  page  66. 

*  British  Medical  Journal,  191 2,  Vol.  I,  page  694. 

*  The  Industrial  Diseases  of  South  Africa.     Reprinted  from  the  Medical  Journal  of  South 

Africa,  February,  1914. 
'  Annual  Report,  1913,  page  63. 
^Transvaal  Medical  Journal,  Oct.,  1912,  page  72. 

'  tJberder  Ursprung  der  Anthrakose  derLungen  Verlag  von  Julius  Springer,  Berlin,  191 1. 
'Transvaal  Chamber  of  Mines,  24th  Annual  Report,  1913,  page  578. 


CHAPTER  II 
DISEASES  OF  THE  BLOOD,  CIRCULATORY  SYSTEM  AND  KIDNEYS 

BY  THOMAS  S.  LEE,  M.  D..  Washington,  D.  C. 

As  this  chapter  must  of  necessity  be  Hmited  in  its  scope,  only  the  main 
features  of  the  diseases  can  be  considered.  For  convenience  these  diseases 
will  be  treated  under  their  usual  headings  and  special  attention  given  to 
the  facts  that  bear  more  or  less  directly  on  the  occupational  aspects  of 
the  subject. 

Brief  mention  is  made  of  the  trades  or  occcupations,  in  which  statistics 
show  that  these  diseases  are  unusually  frequent,  a  fuller  consideration  of 
the  different  occupations  being  found  under  their  separate  headings  in 
another  section  of  the  book. 

The  etiological  factors  considered  being  only  those  unavoidably  con- 
nected with  the  various  industries,  no  mention  is  made  of  the  effects  of 
alcohol  and  syphilis  which,  though  unusually  prevalent  among  certain 
classes  of  workers,  are  in  no  way  necessarily  connected  with  the  occupa- 
tions themselves. 

Broadly  speaking,  the  etiological  factors  of  the  diseases  of  the  blood, 
the  circulatory  system  and  the  kidneys,  considered  as  occupational  dis- 
eases, are  either  those  that  act  mechanically,  such  as  strain  and  exposure 
to  physical  forces,  or  the  industrial  chemical  poisons.  The  defective 
hygienic  surroundings  under  which,  almost  of  necessity,  many  trades  are 
carried  on  also  have  their  part  in  causing  certain  of  these  diseases. 

DISEASES  OF  THE  BLOOD 

Under  the  heading  of  Diseases  of  the  Blood  will  be  considered  the  sec- 
ondary or  symptomatic  anaemias,  as  well  as  certain  pathological  conditions 
of  the  blood  that  are  brought  about  by  industrial  poisons.  These  latter 
are  not  in  themselves  disease  entities,  but  are  commonly  important  features 
of  the  poisoning  and  not  infrequently  dominate  the  picture  of  the  syndrome. 
A  full  account  of  the  more  important  poisons  i%  given  in  the  preceding 
chapters. 

Hemoglobinemia. — The  abnormal  presence  of  hemoglobin  in  the  plasma 
of  the  blood  is  brought  about  by  hemolysis.  In  this  manner  the  hemoglobin 
is  discharged  from  the  erythrocytes,  and  to  a  large  extent  they  are  de- 
stroyed. Among  the  industrial  poisons  causing  hemolysis  may  be  mentioned 
arseniuretted  hydrogen  and  carburetted  hydrogen,  also  phosphuretted  hy- 

235 


236  SYSTEMIC    OCCUPATIONAL   DISEASES 

drogen  which  together  with  arseniuretted  hydrogen  is  Hberated  when  ferro- 
siHcon  comes  into  contact  with  water.  Many  cases  have  been  reported  in 
recent  years  in  ships  carrying  f errosilicon.  If,  as  often  happens,  the  hemolysis 
is  rapid  and  overwhelming,  a  fatal  result  ensues  with  tissue  suffocation.  If 
less  severe,  the  patient  presents  the  typical  symptoms  of  acute  secondary 
angemia,  whereas  a  moderate  hemolysis  acting  over  a  longer  period  of  time 
is  one  of  the  recognized  causes  of  chronic  secondary  anaemia. 

Methemoglobinemia.- — Methemoglobin  is  found  partly  in  the  erythro- 
cytes and  partly  in  the  plasma  as  the  result  of  an  associated  hemolysis.  It 
is  considered  isomeric  with  oxyhemoglobin,  but  is  a  more  stable  compound 
and  is  not  capable  of  carrying  on  its  oxygenating  functions.  It  imparts  a 
brownish  or  chocolate  color  to  the  blood  and  is  easily  recognizable  by  its 
characteristic  spectrum.  Among  the  industrial  poisons  causing  methemo- 
globinemia may  be  mentioned  benzene,  nitrobenzol,  nitrous  gases,  phenylhy- 
drazine,  aniline,  and  various  aniline  dye  stuffs.  Many  other  substances  may 
bring  about  this  condition,  but  they  appear  to  be  of  greater  medical  or 
chemical  than  industrial  interest. 

Sulphemoglobinemia. — Sulphemoglobin  is  formed  by  the  action  of  sul- 
phuretted hydrogen  on  the  blood,  and  it  has  been  found  that  in  the  presence 
of  a  reducing  or  oxidizing  agent  very  small  quantities  may  bring  about  this 
change.  It  gives  the  blood  a  purple  color  and  has  its  characteristic  spectrum, 
slightly  different  from  that  of  methemoglobin.  The  first  cases  were  reported 
by  Van  der  Bergh  in  1905.  These  were  idiopathic  or  enterogenous.  A 
number  of  cases  have  been  reported  since,  both  of  this  type  and  following 
industrial  poisoning. 

Symptomatology  of  Methemoglobinemia  and  Sulphemoglobinemia. — ^Large 
doses  of  some  of  the  poisons  causing  these  disturbances,  as  for  example  the 
breathing  of  air  charged  with  a  high  proportion  of  sulphuretted  hydrogen, 
are  rapidly  fatal.  Death  may  be  preceded  by  a  short  stage  of  unconscious- 
ness, with  slow  pulse,  Cheyne-Stokes  respiration  and  increasing  asphyxia — ■ 
symptoms  doubtless  due  to  bulbar  paralysis.  In  the  more  prolonged  and 
non-fatal  cases  marked  cyanosis  develops — a  gray-blue  discoloration  of  the 
skin  and  mucous  membranes.  Headache  with  gastric  disturbances  and  gen- 
eral muscular  weakness  are  associated  symptoms.  In  the  enterogenous  cases, 
more  particularly,  it  has  been  noted  that  chronic  diarrhea  is  present  in  met- 
hemoglobinemia and  constipation  in  sulphemoglobinemia.  The  blood  may 
not  show  great  abnormality  on  ordinary  examination,  a  moderate  degree 
of  anaemia  being  present  in  the  acute  cases.  Spectroscopic  examination 
is  pathognomonic. 

Carboxyhemoglobinemia.^ — This  is  typical  of  carbon  monoxide  poison- 
ing. The  blood  is  bright  cherry-red  in  color,  flows  very  freely,  and  presents 
a  definite  spectrum.  Carbon  monoxide  has  an  affinity  for  hemoglobin 
more  than  200  times  greater  than  that  of  oxygen,  so  that  even  small 
amounts  in  the  inhaled  air  are  readily  absorbed  by  the  blood  and  retained 


DISEASES    OF    THE    BLOOD,    CIRCULATORY    SYSTEM    AND    KIDNEYS      237 

in  stable  combination.  Carboxyhemoglobin  does  not  react  with  reducing 
agents  and  is  useless  for  purposes  of  oxygenation.  It  has  been  found  by 
experiment  that  the  effects  of  the  poisoning  are  not  noticed  until  about  one- 
third  of  the  hemoglobin  has  been  converted  into  carboxyhemoglobin,  that 
they  become  urgent  when  the  corpuscles  are  about  half  saturated  and  that 
death  usually  occurs  when  the  respiratory  capacity  of  the  blood  has  been 
reduced  to  about  30  per  cent,  of  the  normal.  A  leucocytosis  is  sometimes 
present  and  in  the  chronic  cases  an  increase  in  the  number  of  the  erythrocytes. 

Symptomatology. — The  symptoms  are  mainly  due  to  the  changes  in  the 
blood,  and  defective  internal  respiration.  In  a  highly  contaminated  at- 
mosphere the  attack  may  be  very  sudden.  The  person  falls  unconscious 
with  loss  of  muscular  power,  and  the  heart's  action,  becoming  progressively 
weaker,  soon  stops.  Usually  the  symptoms  of  acute  poisoning  are  gradual 
in  their  onset — first  severe  frontal  headache,  throbbing  of  the  arteries,  buzz- 
ing in  the  ears,  vertigo,  nausea  and  vomiting,  muscular  weakness,  dyspnoea 
and  oppression,  with  rapid  pulse  and  respirations.  Pale  or  bright  red  patches 
are  seen  upon  the  skin  due  to  local  dilatation  of  the  peripheral  vessels  and 
the  change  in  the  color  of  the  blood.  Sometimes,  however,  a  bluish  discolora- 
tion of  the  skin  is  more  noticeable.  Later  there  are  motor  disturbances, 
tremors,  convulsions  and  paralyses  with  loss  of  consciousness.  Death  is 
usually  due  to  respiratory  paralysis  and  asphyxia;  or  recovery  may  occur 
even  after  sevete  poisoning,  with  a  slow  convalescence. 

Chronic  poisoning  is  characterized  by  headache,  dizziness,  nausea,  im- 
pairment of  memory,  muscular  weakness  and  secondary  anaemia. 

Cyamnethemoglobinemia  is  present  in  poisoning  by  the  cyanogen  com- 
pounds, especially  by  the  fumes  of  hydrocyanic  acid  and  the  cyanides.  The 
cyanogen  ion  acts  both  upon  the  hemoglobin,  forming  a  new  compound  with 
characteristic  spectrum,  and  upon  the  tissues,  directly  inhibiting  their 
power  of  oxygen  absorption.  The  result  is  tissue  asphyxia.  The  blood  is  a 
bright  red  color  and  the  venous  return  flow  resembles  the  arterial.  The 
alkaUnity  of  the  blood  is  diminished  and  lactic  acid  appears  therein. 

Symptomatology. — Death  follows  quickly  on  the  inhalation  of  large 
quantities.  It  may  be  preceded  by  a  stage  of  deep  unconsciousness,  with 
dyspnoea  and  heart  failure.  In  the  acute  but  non-fatal  cases  there  is  head- 
ache, vertigo,  palpitation,  dyspnoea  and  great  prostration.  Convulsions  and 
loss  of  consciousness  may  follow.  There  is  usually  cyanosis  of  the  skin  and 
mucous  membranes.  In  those  who  are  exposed  to  constant  inhalations  of 
minute  quantities  of  the  vapor,  a  form  of  chronic  poisoning  may  develop, 
in  which  all  of  the  above  symptoms  are  present  in  a  minor  degree.  Anorexia, 
nausea  and  disturbance  of  the  gastro-intestinal  functions  are  also  present, 
and  the  picture  of  a  chronic  secondary  anaemia  is  presented. 

Acute  Secondary  Anaemia. — As  an  occupational  disease,  this  is  caused  by 
acute  intoxication  by  various  industrial  poisons.  These  comprise  for  the 
most  part  those  mentioned  in  the  previous  section,  and  in  many  cases  other 


238  SYSTEMIC    OCCUPATIONAL   DISEASES 

signs  of  acute  anaemia  are  added  to  the  changes  in  the  hemoglobin.  Acute 
anaemia  may  also  be  caused  by  other  poisons,  such  as  carbon  disulphide  or 
mercury,  which  cause  rapid  destruction  of  the  elements  of  the  blood. 

Symptomatology. — The  condition  is  often  ushered  in  with  nausea  and 
vomiting.  Dyspnoea  is  an  early  and  constant  symptom  and  there  is  usually 
a  feeling  of  anxiety  and  extreme  difficulty  in  breathing.  With  this  is  asso- 
ciated faintness,  vertigo  and  a  small  rapid  pulse  and  subnormal  temperature. 
Headache  and  severe  nervous  symptoms  are  frequently  present.  There  is 
marked  pallor  of  the  skin  except  in  those  cases  where  the  hemoglobin  is  de- 
stroyed, when  we  have  the  various  characteristic  changes  previously  noted. 
The  blood  picture  may  be  that  of  chronic  secondary  anaemia,  described  in 
the  next  section,  but  often  resembles  the  pernicious  type — great  reduction 
in  erythrocytes  with  a  relatively  high  hemoglobin  content  and  high  color 
index,  extreme  variations  in  shape  and  size  of  the  erythrocytes  with  an  excess 
of  oversized  cells,  polychromatophilia,  many  normoblasts  and  megaloblasts. 
A  leucocytosis  is,  however,  usually  present,  except  in  the  case  of  benzol 
poisoning,  where  there  is  a  marked  leucopenia. 

Treatment. — Oxygen  is  our  most  valuable  agent  in  combating  the 
sudden  and  extreme  diminution  of  the  hemoglobin  content  of  the  blood. 
Oxygen  treatment,  as  stated  by  Rambousek,  "rests  on  the  fact  that  by  rais- 
ing the  pressure  of  the  oxygen  from  113  mm.,  as  it  is  generally  in  ordinary 
air,  to  675  mm.,  which  is  reached  in  the  presence  of  pure  oxygen,  the 
quantity  of  oxygen  absorbed  by  the  blood  rises  from  0.3  to  1.8  per  100  c.c. 
Further,  the  saturation  of  the  hemoglobin  undergoes  an  increase  of  2.4 
per  cent."  This  increase  of  oxygen  in  the  blood,  he  says,  can  save  life  in 
cases  where,  through  poisoning,  a  deficiency  of  oxygen  has  resulted.  Special 
apparatus  for  the  administration  of  oxygen  should  be  provided  wherever 
there  is  a  likelihood  of  industrial  blood  poisoning.  In  acute  hemoglobin 
transformation  venesection  with  infusion  of  normal  saline  or  direct  trans- 
fusion of  blood  is  indicated.  This  relieves  the  blood  of  at  least  a  part  of  its 
useless  hemoglobin  compound  and  remaining  toxin,  and  may  just  suffice 
to  enable  the  organism  to  turn  the  scale  in  its  efforts  for  regeneration. 

During  convalescence  the  case  should  be  treated  as  one  of  chronic  second- 
ary anaemia. 

Chronic  Secondary  Anaemia. — This  disease  may  be  due  to  the  effects 
of  the  insanitary  conditions  that  necessarily  surround  certain  occupations. 
Bad  air,  prolonged  exposure  to  heat,  frequent  and  sudden  changes  of  tem- 
perature, and  irregularity  in  eating  all  tend  to  bring  about  a  condition  of 
inanition  in  which  a  typical  secondary  anaemia  plays  the  conspicuous  part. 
Statistics  show  that  this  is  unusually  prevalent  among  bakers,  iron  and 
foundry  workers,  miners  and  smiths.  Less  typical  forms  of  chronic  second- 
ary anaemia,  characterized  in  some  cases  by  special  features,  are  caused  by 
the  continued  or  frequent  action  of  poisons  to  which  industrial  workers  are 
accidentally  or  necessarily  exposed.     Among  these  poisons  may  be  men- 


DISEASES    OF    THE    BLOOD,    CIRCULATORY    SYSTEM    AND    KIDNEYS      239 

tioned  lead,  mercury,  antimony  (which  causes  also  leucopenia  and  eosino- 
philia),  phosphorus,  chlorine  and  bromine,  as  also  the  dust  inhaled  in  the 
cotton  and  jute  industries.  Many  of  the  poisons  causing  acute  anaemia 
may  also  cause  the  chronic  form,  if  they  act  in  smaller  quantities  over  a 
longer  period  of  time. 

Symptomatology . — Pallor  of  the  skin  and  mucous  membranes  is  marked. 
There  is  loss  of  weight,  with  muscular  weakness  and  loss  of  mental  vigor. 
The  appetite  is  poor,  the  digestion  impaired,  the  nourishment  fails.  There 
is  usually  palpitation,  an  irritable  heart,  rapid  pulse,  with  feelings  of  faint- 
ness  and  vertigo,  and,  later,  signs  of  inefficient  circulation,  such  as  constant 
fatigue,  rapid  respiration,  dyspnoea  on  exertion,  and  swelling  of  the  feet. 
There  may  be  extravasations  of  blood  into  the  mucous  membranes,  petechiae 
in  the  skin,  or  retinal  hemorrhages.  There  is  frequently  a  slight  remittent 
fever. 

The  blood  shows  a  moderate  reduction  in  the  number  of  erythrocytes 
to  between  2,000,000  and  4,000,000  per  cu.  mm.,  greater  proportionate 
reduction  of  hemoglobin,  giving  a  color  index  of  about  0.8  to  0.5;  many  ery- 
throcytes are  pale,  irregular,  nucleated,  polychromatophilic;  the  leucocytes 
are  slightly  increased  in  number,  usually  the  multinuclear  neutrophiles. 

In  chronic  hemolysis  the  blood  approaches  the  type  of  pernicious  anaemia: 
a  great  reduction  in  the  number  of  erythrocytes,  which  frequently  fall  below 
2,000,000  per  cu.  mm.,  great  variations  in  size  with  a  general  average  in- 
crease, and  a  relatively  high  hemoglobin  content,  giving  a  high  color  index, 
and  the  presence  of  many  normoblasts  and  megaloblasts. 

In  chronic  lead  poisoning  many  of  the  erythrocytes  are  small  and  with 
basic  stains  exhibit  a  sprinkling  of  blue-black  dots  upon  the  corpuscle,  known 
as  stippling  or  basophilic  granulation.  This  may  be  associated  with  the 
blood  picture  of  pernicious  anaemia,  but  often  it  is  accompanied  by  but  few 
other  abnormal  signs. 

Treatment. — But  little  can  be  done  in  the  way  of  treatment  without 
removal  of  the  cause.  The  patient  must  be  placed  in  good  hygienic  sur- 
roundings and  the  poison  eliminated  where  possible.  This  frequently  neces- 
sitates a  change  of  occupation.  Fresh  air  and  a  nutritious  diet  are  the 
main  points  to  be  insisted! upon.  I^^on  in  any  form  and  in  full  doses  is 
indicated,  with  arsenic  as  an  adjuvant.  Care  must  be  taken  to  avoid  con- 
stipation.    In  the  severe  cases  rest  in  bed  is  necessary  for  a  certain  period. 

DISEASES  OF  THE  CIRCULATORY  SYSTEM 

Primary  Cardiac  Overstrain. — Although  many,  perhaps  most,  of  the 
persons  who  are  subject  to  attacks  of  cardiac  failure  with  dilatation  are 
possessors  of  a  damaged  myocardium,  most  authors  now  agree  that  disturb- 
ance, inefficiency  or  failure  of  the  circulation  may  be  brought  about  in  a 
healthy  heart  by  overstrain.     As  an  occupational  disease,  primary  cardiac 


240  SYSTEMIC    OCCUPATIONAL   DISEASES 

overstrain  is  frequent  among  soldiers,  porters,  miners,  blacksmiths  and  metal 
workers. 

Pathology. — The  cavities  of  the  heart  are  usually  dilated  and  the  muscular 
walls  frequently  show  a  certain  amount  of  antecedent  hypertrophy,  without 
degeneration.  The  muscular  tonicity  is  diminished,  but  otherwise  the  heart 
is  normal. 

Symptomatology. — The  cardinal  symptom  is  a  limitation  of  the  field  of 
cardiac  response,  the  patient  being  unable  to  support  the  least  exertion  with- 
out distress,  though  he  may  be  comfortable  when  at  rest.  There  is  frequently 
palpitation,  cardiac  pain,  a  sense  of  pressure  or  constriction  over  the  chest, 
often  restlessness,  headache,  buzzing  in  the  ears  and  vertigo.  The  pulse  is 
small,  feeble  and  rapid,  and  sometimes  irregular;  the  cardiac  impulse  is  wavy 
and  diffused;  the  area  of  dullness  enlarged;  the  sounds  distant  and  feeble, 
or  short  and  sharp;  and  a  soft  blowing  systolic  murmur  of  functional  mitral 
or  tricuspid  insufficiency  is  often  present.  In  the  more  severe  cases,  or  with 
those  who  make  an  effort  to  continue  their  work,  dyspnoea,  oedema,  and  other 
symptoms  of  cardiac  decompensation  ensue. 

Treatment. — For  the  sake  of  emphasis  the  treatment  might  almost  be 
summed  up  in  one  word — prolonged  rest.  Some  weeks  or  months  are  none 
too  long  in  a  moderately  severe  case.  This  must  of  course  be  supplemented 
by  adjuvant  measures  as  to  hygiene,  diet,  etc.  Moderate  doses  of  digitalis, 
I  to  2  grains  a  day,  are  a  great  aid  in  restoring  the  tonicity  of  the  heart  muscle. 
The  return  from  complete  rest  to  full  activity  must  be  made  very  gradually. 
What  can  be  accomplished  by  care  and  prolonged  treatment  is  shown  by  the 
remarkable  results  obtained  by  da  Costa  in  many  very  severe  cases  among 
Union  soldiers  of  the  Civil  War.  The  fact  that  many  of  these  were  again 
able  to  perform  strenuous  work  and  lead  perfectly  healthy  lives  is  further 
proof,  it  any  were  needed,  that  cardiac  overstrain  and  dilatation  may  be  a 
primary  disease. 

Functional  Affections  of  the  Heart. — Recent  advances  in  cardiac  path- 
ology have  tended  to  limit  considerably  the  field  of  purely  functional  affec- 
tions of  the  heart.  It  has  beeen  shown  that  many  diseases  previously 
considered  functional  are  in  reality  due  to  lesions  of  some  part  of  the  cardiac 
musculature.  It  is  still  customary  and  convenient,  however,  to  group 
under  this  heading  various  disturbances  of  the  rate,  rhythm  or  force  of  the 
heart's  action.  Of  these,  palpitation,  tachycardia,  and  bradycardia  are 
frequently  caused  by  the  chemical  industrial  poisons  and  may  be  the  chief 
manifestation  of  such  poisoning,  but  more  often  are  only  a  part  of  the  general 
symptom-complex. 

Palpitation  is  the  forcible  overaction  of  the  heart,  whereby  its  beating 
becomes  disagreeably  perceptible  to  the  individual.  It  may  or  may  not  be 
associated  with  some  form  of  irregularity,  although  it  must  be  emphasized 
that  the  great  majority  of  the  arrhythmias  are  now  thought  to  be  due  to 
myocardial  diseases  or  degeneration.     The  industrial  poisons  most  likely 


DISEASES    OF    THE    BLOOD,    CIRCULATORY    SYSTEM    AND    KIDNEYS      24I 

to  cause  palpitation  are  amyl  acetate,  carboij  monoxide,  naphtha  and  gaso- 
line, hydrocyanic  acid  and  the  cyanides,  and  tobacco  inhaled  as  dust  in  the 
process  of  manufacture. 

The  term  tachycardia  is  usually  appUed  to  a  condition  of  marked  rapidity 
of  the  heart's  action,  independent  of  fever  or  evident  physical  cause  such  as 
exercise  or  excitement.  It  may  be  continuous  or  intermittent  and  the  rhythm 
may  be  regular  or  irregular.  Its  etiology  is  varied,  the  more  common  forms 
being  due  to  heterogenetic  impulse  formation,  and  being  designated  ac- 
cording to  their  nature  as  auricular  flutter,  auricular  fibrillation,  essential 
paroxysmal  tachycardia.  More  rarely  the  cause  is  a  destructive  lesion  of  the 
pneumogastric  nerve.  These  forms  must  be  differentiated  from  the  tachy- 
cardia due  to  chemical  poisoning.  As  an  industrial  disturbance  this  is  usually 
associated  with  poisoning  by  acetaldehyde,  aniline  and  the  nitrophenols. 

Bradycardia  indicates  a  condition  in  which  the  heart's  action  is  ab- 
normally slow,  although  here  it  is  difficult  to  set  the  limits  between  health  and 
disease.  Although  some  people  are  said  to  have  had  healthy  lives  with 
extremely  slow  hearts,  a  pulse  below  50  must  practically  always  indicate 
some  disturbance  either  organic  or  functional.  Except  in  the  terminal 
stages  of  disease,  a  pulse  below  35  is  usually  due  to  heart-block,  while  one 
between  35  and  50  may  result  from  many  causes.  Bradycardia  is  more 
frequent  than  palpitation  or  tachycardia  in  the  severe  cases  of  chemical 
poisoning,  and  is  a  usual  accompaniment  of  poisoning  by  carbon  monoxide, 
hydrocyanic  acid  and  the  cyanides  and  sulphuretted  hydrogen. 

Pathology. — -These  functional  cardiac  disturbances  in  chemical  poisoning 
are  due  to  the  direct  action  of  the  poisons  on  the  heart  or  its  nervous  mechan- 
ism, or  to  the  blood  changes  which  they  produce.  In  one  or  the  other  mannei 
the  cardiac  musculature  may  be  deprived  of  its  proper  nutrition  and  rendered 
inefficient;  or  the  inner  stimulus  of  the  blood  on  which  the  heart  depends  for 
its  automatic  rhythmicity  may  be  disorganized;  or  the  centers  or  terminals 
of  the  vagus  or  accelerator  nerves  may  be  either  irritated  or  depressed, 
according  to  the  nature  or  selective  action  of  the  poison. 

Treatment. — The  first  object  to  be  attained  in  the  treatment  of  these 
toxic  conditions  is  the  elimination  of  the  poison,  hence  free  catharsis  and 
diuresis  are  always  indicated,  and  in  the  acute  cases  chemical  antidotes 
where  possible.  Rest  to  a  considerable  degree  is  called  for,  although  the 
more  nearly  the  disturbance  approaches  the  purely  nervous  type,  the  less 
is  this  necessary  or  advisable.  Here  well-regulated  exercise  may  often  be 
substituted. 

For  palpitation  and  tachycardia  the  bromides  of  potassium,  ammonium 
and  strontium  are  of  some  value,  and  large  doses  of  aconite  sometimes  act 
favorably.  The  application  of  an  ice-bag  or  a  cold-water  coil  over  the 
heart  is  often  the  best  remedy  in  the  acute  cases.  If  the  bradycardia  is 
due,  as  is  often  the  case,  mainly  to  increased  inhibition,  atropine  is  indi- 
cated for  its  selective  action  on  the  vagal  terminals.  Here,  however,  we 
16 


242  SYSTEMIC    OCCUPATIONAL   DISEASES 

are  more  likely  to  have  some  signs  of    circulatory  inefl&ciency  and    must 
often  have  resort  to  caffeine  or  digitalis. 

Acute  Endocarditis. — Acute  endocarditis  usually  follows  or  is  one  of  the 
manifestations  of  acute  rheumatic  fever,  and  is  frequently  met  with  as  an 
occupational  disease  in  accordance  with  the  prevalence  of  the  latter  among 
certain  workers.  Although  this  form  of  rheumatism  is  now  generally  conceded 
to  be  due  to  a  specific  organism,  the  infecting  agent  is  doubtless  widespread, 
and  certainly  attacks  with  greater  frequency  those  exposed  to  severe  cold 
or  dampness,  and  especially  to  sudden  changes  of  temperature.  The  con- 
tinued inhalation  of  certain  forms  of  dust  seems  also  to  be  a  predisposing 
cause.  These  conditions  are  the  necessary  accompaniment  of  certain  occu- 
pations, and  statistics  show  that  acute  rheumatism  in  its  arthritic,  tonsillar, 
or  endocarditic  manifestations  is  unusually  frequent  among  cotton  spinners, 
wool  sorters  and  drapers,  brewers,  bakers,  carpenters  and  stokers.  Rheu- 
matic endocartitis,  therefore,  is  an  increased  risk  attending  these  occupations. 

'Pathology. — Its  pathology  here  in  no  way  differs  from  that  seen  in  other 
cases;  the  arrest  of  the  organisms  upon,  or  more  often  within,  the  tissue  of  the 
valve,  or  on  the  lining  membrane  of  the  heart  chambers,  the  deposition  of 
blood  platelets,  leucocytes  and  fibrin  in  varying  proportions,  forming  minute 
vegetations  of  a  warty  or  verrucose  appearance;  later,  the  organization  of 
these  vegetations  by  the  disintegration  and  absorption  of  the  blood  cells  and 
fibrin,  and  the  outgrowth  of  connective  tissue,  leading  ultimately  to  sclerosis, 
thickening  and  deformity  of  the  valves. 

Symptomatology. — The  symptomatology  of  acute  rheumatic  or  simple 
endocarditis  is  not  very  characteristic.  There  is  usually  a  slight  fever,  or  an 
exacerbation  of  a  previously  existing  fever,  often  palpitation  and  a  pulse  rate 
out  of  proportion  to  the  fever,  usually  some  respiratory  distress,  with  dyspnoea 
on  exertion,  occasionally  slight  oedema,  ascites  or  enlargement  of  the  liver. 
Anaemia  and  anorexia  are  often  associated  symptoms.  The  physical  signs 
are  uncertain.  There  is  usually  accentuation  and  sometimes  reduplication 
of  the  pulmonic  second  sound,  and  a  systoHc  bruit  at  the  apex.  The  latter, 
however,  is  more  often  a  sign  of  myocarditis  than  of  endocarditis,  and  entirely 
disappears  with  the  subsidence  of  the  acute  attack.  Many  cases  are  latent, 
and  the  condition  is  unsuspected,  only  to  become  apparent  later  as  a  chronic 
endocarditis. 

Treatment. — The  treatment  of  acute  rheumatic  endocarditis  should  be 
mainly  prophylactic,  and  our  present  knowledge  of  the  subject  seems  to 
indicate  that  tonsillectomy  should  be  considered  in  all  patients  who  have  had 
rheumatic  infections  in  any  of  its  forms,  or  who  seem  to  be  specially  exposed 
to,  or  susceptible  to  it.  The  further  prophylactic  treatment  consists  in  pro- 
longed rest  during  an  acute  rheumatic  infection.  This  is  more  potent  than 
salicylates  or  other  specific  treatment  in  decreasing  the  chances  of  endo-  _ 
carditis.  If  endocarditis  develops,  the  rest  should  be  still  more  prolonged 
and  the  active  treatment  symptomatic. 


DISEASES    OF    THE    BLOOD,    CIRCULATORY    SYSTEM    AND    KIDNEYS      243 

Chronic  Endocarditis. — This  may  be  a  sequel  of  acute  endocarditis;  but 
more  frequent,  as  an  occupational  disease,  is  the  sclerotic  type,  of  insidious 
onset  and  gradual  development,  which  is  usually  but  one  manifestation  of 
a  more  or  less  generalized  sclerosis  affecting  the  heart,  arteries  and  kidneys, 
and  often  the  liver  and  spleen.  Long-continued  overexertion  or  frequently 
repeated  severe  muscular  strain  are  fundamental  causes  of  these  lesions,  and 
to  these  may  be  added  the  efifects  of  chronic  lead  poisoning  and  chronic 
anaemia.  Among  the  other  causes  that  are  common  among  industrial  workers 
are  gout  and  intestinal  toxaemia  due  to  the  prolonged  use  of  an  improper  diet. 
An  abnormally  high  percentage  of  chronic  heart  cases  are  found  among  iron 
and  metal  workers  who  wield  heavy  hammers  and  carry  heavy  burdens  in 
foundries,  blacksmiths,  miners,  bakers,  soldiers,  and  lead  workers. 

Pathology. — The  pathology  of  chronic  endocarditis  may  be  briefly  sum- 
marized as  follows:  sometimes  as  a  sequence  of  an  acute  endocarditis,  more 
often  as  a  slow  and  insidious  growth  as  a  result  of  the  causes  above  referred 
to,  the  edges  of  the  valves  become  thickened  and  present  small  nodular  promi- 
nences. The  substance  of  the  valve  loses  its  translucency  and  its  .delicate 
tenuity.  Later  there  is  a  further  overgrowth  of  fibrous  tissue,  causing  marked 
thickening  of  the  valves  or  mural  endocardium  or  both.  The  chordae  ten- 
ding also  are  frequently  affected.  The  fibrous  tissue  then  contracts  and  pro- 
duces shortening  of  the  chordae  and  gross  deformity  of  the  valvular  segments, 
causing  either  a  narrowing  of  the  orifice,  or  a  retraction  and  incompetency 
of  the  valves,  or  both.  Finally  lime  salts  are  frequently  deposited  in  the 
sclerotic  tissue,  so  that  the  remnants  of  the  valve  and  the  orificial  ring  may 
become  a  calcareous  mass,  quite  ineffectual  for  serving  its  natural  function. 

Symptomatology. — The  symptoms  of  chronic  endocarditis  are  those  of 
chronic  valvular  disease  in  general.  When  the  heart's  hypertrophy  and  its 
muscular  integrity  keep  pace  with  the  disability  due  to  the  valvular  defect, 
they  are  but  slight,  and  are  evidenced  chiefly  by  a  limitation  of  the  field  of 
cardiac  response.  If  this  is  overstepped,  as  it  almost  necessarily  will  be  at 
an  early  stage  in  the  patients  under  consideration,  there  will  be  some  dyspnoea 
and  general  weakness,  often  with  palpitation  and  precordial  distress.  As 
decompensation  sets  in  gradually,  or  often  in  more  or  less  sudden  and  recur- 
ring attacks,  a  train  of  symptoms  is  presented  due  to  (i)  the  slowing  of  the 
circulation  with  diminished  supply  of  oxygen  and  accumulation  of  carbon 
dioxide,  (2)  the  overfilling  of  the  veins  with  blood,  and  (3)  reflex  nervous  dis- 
turbances. The  symptoms  will  vary  according  to  the  part  of  the  organism 
chiefly  affected  by  this  venous  stasis:  dysnpoea,  cough,  cardiac  asthma,  pul- 
monary congestion,  hemorrhage  and  oedema  of  the  lungs;  cyanosis,  oedema 
of  the  extremities,  ascites,  hydrothorax;  congestion  of  the  liver,  indigestion, 
occasionally  jaundice;  congestion  of  the  kidney,  with  scanty  and  albuminous 
urine;  headache,  restlessness,  sleeplessness,  irritabihty,  and  sometimes  more 
serious  nervous  and  mental  disturbances.  The  physical  signs  vary  with  the 
lesion  and  with  the  valve  affected  and  need  not  be  rehearsed  here. 


244  SYSTEMIC   OCCUPATIONAL  DISEASES 

Treatment. — The  treatment  of  chronic  endocarditis  in  the  class  of  patients 
under  consideration  would  seem  to  consist  primarily  in  devising  some  means 
of  lessening  their  cardiac  strain.  If  the  patient  is  seen  early  and  this  end  can 
be  obtained,  he  may  reasonably  look  forward  to  many  years  of  useful  work. 
The  two  most  important  factors  in  obtaining  it  are:  first,  personal  instruction 
in  cardiac  hygiene,  second,  the  obtaining  of  some  less  arduous  work  than  that 
which  has  brought  about  or  favored-  the  disease.  In  our  clinic  we  are  con- 
stantly urging  patients  to  seek  positions  such  as  watchmen,  janitors,  or  mes- 
sengers, or  other  such  places,  where  they  may  earn  a  hvelihood  with  the  least 
effort.  It  is  often  surprising  how  little  intelligent  workingmen  may  know  of 
personal  hygiene,  and  especially  of  its  bearing  on  their  cardiac  condition. 
It  is  important  therefore  to  give  definite  instructions  as  to  overwork  and  rest, 
strain  and  worry,  clothing,  ventilation,  bathing,  diet,  and  the  care  of  the 
bowels.  The  injurious  effect  of  alcohol  should  also  be  clearly  explained.  As 
chronic  anesmia  is  frequently  a  factor  in  these  cases,  it  should  receive  appro- 
priate treatment.  When  the  case  goes  on  to  some  grade  of  cardiac  decom- 
pensation, the  patient  should  be  confined  to  bed  and  is  usually  better  cared  for 
in  a  hospital.  As  these  patients  so  often  have  made  an  effort  to  work  to  the 
last  moment  possible,  and  have  thus  weakened  the  myocardium  out  of  all 
proportion,  it  would  seem,  to  their  endocardial  lesion,  far  better  results 
are  obtained  and  more  time  is  gained  by  them  in  the  end,  by  prolonging  the 
rest  in  bed  to  the  limit;  that  is,  far  beyond  what  the  patient  himseff  feels 
is  necessary.  The  chief  difficulty  usually  comes  in  persuading  the  patient 
that  this  is  desirable.  In  our  clinic  we  do  not  hesitate  to  keep  patients  with 
only  moderately  severe  decompensation  in  bed  for  2  months,  and  have  found 
that  the  results  more  than  repaid  us.  After  the  period  of  complete  rest, 
systematic  exercises  are  instituted  that  the  patient  may  return  very  gradu- 
ally to  the  amount  of  exertion  necessary  to  the  avocation  decided  upon. 
The  medicinal  treatment  of  chronic  endocarditis  is  of  greatest  importance  in 
the  stage  of  decompensation.  Digitalis,  its  products,  and  congeners  are  the 
drugs  par  excellence  in  this  condition.  To  give  a  full  account  here  of  the 
use  and  effect  of  digitahs,  its  indications  and  contraindications  would  lead  us 
too  far  afield.  Suffice  it  to  give  a  few  general  principles  which  to-day  guldens 
in  its  usage.  In  the  failing  heart  of  chronic  endocarditis  digitalis  is  seldom, 
if  ever,  contraindicated.  It  must,  however,  often  be  used  tentatively  and 
with  great  caution.  We  give  it  in  full  doses  and  with  the  expectation  of  the 
most  brilliant  results  in  cases  of  auricular  fibrillation,  especially  if  they  be 
associated  with  mitral  disease;  and  in  secondary  low  blood  pressure  cases, 
which  have  retained  a  fairly  good  heart  muscle.  We  give  smaller  doses  and 
look  for  a  slower  and  less  certain  result  in  aortic  cases  with  a  regular  pulse 
or  with  premature  contractions.  And  finally  we  use  the  drug  with  great 
caution,  beginning  with  small  doses,  in  all  cases  complicated  by  severe 
myocardial  disease  or  degeneration,  especially  of  the  fatty  type. 


DISEASES    OF    THE    BLOOD,    CIRCULATORY    SYSTEM    AND    KIDNEYS      245 

Arteriosclerosis. — Arteriosclerosis,  local  or  general,  is  undoubtedly  the 
commonest  form  of  circulatory  disease  due  directly  to  the  influence  of  occu- 
pation. Two  of  its  etiological  factors  are  prevalent  among  many  industrial 
workers,  namely,  arterial  strain  and  lead  poisoning.  The  former  is  brought 
about  by  prolonged  and  heavy  muscular  exercise,  especially  that  associated 
with  much  lifting,  or  by  constantly  repeated  sudden  efforts,  which  produce  a 
great  increase  in  blood  pressure,  and  ultimately  a  permanent  high  tension. 
This  condition  may  be  also  brought  about  by  occupations  that  are  accom- 
panied by  severe  and  prolonged  mental  strain  or  worry.  The  manner  in 
which  lead  acts  on  the  arterial  system  is  still  somewhat  uncertain.  It  may 
act  directly  as  an  irritant  to  the  arterial  walls,  and  it  certainly  raises  the  blood 
pressure,  probably  by  its  action  on  the  kidneys.  Increased  blood  pressure 
in  itself,  if  sufficiently  long  continued,  inevitably  leads  to  arteriosclerosis. 
A  third  factor  which  is  doubtless  very  prevalent  among  these  patients,  though 
perhaps  no  more  so  than  among  other  classes  of  the  population,  is  intestinal 
auto-intoxication,  more  particularly  that  caused  by  the  decomposition  of 
certain  proteids.  We  find  arteriosclerosis  very  common  among  stevedores, 
iron  and  steel  workers,  smiths,  butchers,  and  soap  boilers,  painters  and  others 
exposed  to  chronic  poisoning  by  the  heavy  metals;  as  also  among  those  who 
are  subjected  to  severe  mental  strain  and  worry. 

Pathology. — In  considering  the  pathology  of  this  disease  it  must  be  re- 
membered that  in  the  aorta  and  larger  branches  of  the  arterial  tree  there  is 
much  elastic  tissue  and  relatively  little  muscle,  while  the  smaller  arteries  and 
those  distributed  to  the  various  organs  contain  much  smooth  muscle  and 
relatively  little  elastic  tissue.  This  of  course  favors  a  greater  variation  in 
the  flow  of  blood  to  the  different  organs  by  means  of  vasoconstriction  and 
vasodilation.  Two  main  types  of  arteriosclerosis  are  described:  the  nodular, 
affecting  chiefly  the  aorta,  and  the  diffuse,  which  mainly  attacks  the  smaller 
vessels.  The  latter  is  the  type  usually  caused  by  chronic  arterial  hyperten- 
sion, in  the  absence  of  syphiKs,  gout  or  other  infectious  or  toxic  agents.  In 
this,  fibrous  overgrowth  is  found  in  all  three  coats  of  the  arteries,  followed 
later  by  degeneration  and  often  by  calcareous  deposition,  especially  in  the 
intima  and  media.  The  distribution  of  diffuse  arteriosclerosis  is  variable. 
Sometimes  all  of  the  arteries  are  more  or  less  affected;  more  often  only 
certain  groups  or  systems.  And  on  this  fact  depends  the  diverse  clinical 
manifestations  of  the  disease. 

Symptomatology. — The  symptoms,  then,  express  themselves  in  groups 
dependent  upon  the  arteries  most  affected.  Hypertension,  though  by  no 
means  a  necessary  accompaniment  of  all  cases  of  arteriosclerosis,  is  constantly 
present  in  those  cases  brought  about  by  muscular  strain  and  lead  poisoning. 
This  means  that  the  main  visceral  trunks  and  their  branches,  usually  referred 
to  as  the  splanchnic  area,  or  the  renal  arteries  are  sclerosed,  frequently  both. 
The  following  are  the  more  notable  symptoms  grouped  under  the  heading  of 
the  system  affected: 


246  SYSTEMIC    OCCUPATIONAL   DISEASES 

(a)  Cardiac:  Pain  in  the  cardiac  area  extending  to  the  shoulders  and 
down  the  arms,  frequently  hyperaesthesia  in  the  same  area,  palpitation  and 
a  sense  of  weight  in  the  precordium;  sometimes  attacks  of  angina  pectoris. 
Myocardial  fibrosis  is  the  natural  sequence  in  these  cases,  with  all  the  signs 
of  cardiac  insufficiency;  dyspnoea,  congestion  of  the  kidneys,  oedema,  ascites, 
hydrothorax. 

{b)  Cerebral:  Headache,  often  severe  and  obstinate,  attacks  of  faintness 
and  vertigo,  nervousness  and  insomnia,  transient  attacks  of  irrationality, 
aphasia  or  partial  paralysis.  The  retinal  arteries  are  often  affected  early,  and 
give  a  characteristic  picture,  accompanied  by  scotomata  and  some  dimness 
of  vision.     Cerebral  hemorrhage  may  be  the  final  outcome. 

(c)  Renal:  Chronic  interstitial  nephritis  of  a  mild  grade  is  very  frequently 
present,  and  the  more  severe  forms  sometimes  supervene. 

(d)  Abdominal:  Disturbances  of  digestion  are  often  the  earliest  symptoms 
manifested,  but  unfortunately  for  purposes  of  diagnosis  are  in  no  way  char- 
acteristic. Attacks  of  severe  abdominal  pain,  often  seen  in  lead  poisoning, 
are  most  likely  due  to  spasm  of  the  partially  sclerosed  abdominal  vessels. 

(e)  Peripheral:  A  similar  spasm  of  the  vessels  of  the  extremities  is 
the  cause  of  the  less  frequent  attacks  of  intermittent  claudication,  with 
severe  pain  and  intermitting  loss  of  function. 

Treatment. — All  that  we  can  hope  to  accomplish  by  the  treatment  of 
an  existing  arteriosclerosis  is  to  arrest  its  progress,  and  to  relieve  some  of 
its  symptoms.  Should  the  patient  be  seen  early,  when  hypertension  is 
alone  present,  in  what  has  been  called  the  presclerotic  stage  of  arterio- 
sclerosis, much  more  may  be  hoped  for.  In  either  case,  the  measures  that 
are  most  useful  are  unfortunately  often  those  that  it  is  difficult  for  the 
workingman  to  carry  out.  Of  the  first  importance  is  the  avoidance  of  the 
causes  of  hypertension,  and  in  most  cases  this  means  change  of  occupation, 
so  as  to  obtain  more  rest  and  greater  freedom  from  strain,  or,  to  avoid  the 
further  saturation  of  the  body  with  lead.  Systematic  exercise,  however, 
which  must  be  often  be  insisted  upon  among  the  leisure  classes,  is  usually 
unnecessary  in  the  cases  under  consideration.  The  diet  is  important,  as 
even  those  engaged  in  laborious  occupations  often  eat  too  much,  or  in- 
judiciously. The  proteid  intake  should  be  reduced  as  much  as  is  consistent 
with  the  maintenance  of  strength,  and  those  forms  of  proteids  used  that 
experience  has  shown  are  least  injurious.  My  own  preference  is  for  cheese 
and  eggs,  and  with  a  moderate  amount  of  these  together  with  the  proteid  ob- 
tained from  breadstuffs  and  some  of  the  vegetables  and  fruits,  the  70  to  80 
grams  a  day  necessary  for  a  hard-working  man  may  be  obtained.  If  meat 
is  allowed  at  all,  it  should  be  eaten  sparingly,  not  oftener  than  once  a  day. 
Medical  opinion  varies  somewhat  as  to  the  deleterious  effect  of  alcohol  in 
arteriosclerosis,  but  certainly  in  the  forms  of  the  disease  under  considera- 
tion, it  is  better  avoided  altogether.  The  bowels  should  be  kept  unusually 
free,  and  this  can,  as  a  rule,  be  accomplished  in  those  of  an  active  life  by 


DISEASES    OF    THE    BLOOD,    CIRCULATORY    SYSTEM    AND    KIDNEYS       247 

careful  dieting.  If  not,  laxatives  may  be  necessary  from  time  to  time.  It 
is  better  to  resort  to  them  as  often  as  need  be,  than  to  allow  constipation 
to  persist,  with  the  resultant  resorption  of  a  greater  amount  of  poisonous 
substances.  Frequent  bathing  is  desirable,  a  tepid  sponge  in  the  morning 
or  a  warm  bath  at  night,  and  the  sweating  incidental  to  labor  is  a  distinct 
advantage.  Too  much  cannot  be  expected  from  medicinal  treatment. 
Potassium  iodide  is  the  classical  remedy,  and  if  given  in  a  suitable  vehicle 
in  small  doses,  it  is  usually  well  borne  and  seems  to  be  of  undoubted  service. 
The  nitrites  are  often  valuable  in  combating  the  symptoms  dependent  on 
hypertension,  though  they  should  not  be  given  constantly  with  the  idea 
of  permanently  lowering  the  pressure.  What  is  not  accomplished  in  this 
way  by  hygiene,  will  hardly  be  by  drugs;  and  indeed  it  is  now  a  common- 
place that  the  optimum  pressure  in  arteriosclerosis,  though  often  less  than 
what  is  found  in  an  untreated  case  is  usually  well  above  the  normal.  Finally, 
we  have  to  deal  with  the  cases  of  secondary  low  blood  pressure  due  to  a 
failing  heart.  Here  digitalis  in  full  doses  is  indicated,  and  is  often  followed 
by  brilliant  results. 

DISEASES  OF  THE  KIDNEYS 

Acute  Nephritis. — Acute  congestion  of  the  kidneys,  followed  usually  by 
acute  nephritis,  as  an  occupational  disease,  is  caused  by  the  inhalation  of 
the  concentrated  fumes  of  turpentine,  vanadium,  arsenic  or  carbolic  acid, 
and  not  infrequently  occurs  among  the  workers  in  these  substances. 

Pathology. — In  these  cases  the  kidneys  are  usually  large,  soft,  and  either 
red  from  the  large  amount  of  blood  present  or  grayish  yellow  with  fatty 
degeneration;  the  capsule  strips  easily;  the  tubular  epithelium  is  swollen, 
hazy,  granular  and  contains  fat  droplets;  the  glomeruli  are  congested  and 
their  capsules  filled  with  blood  cells  and  debris.  There  is  at  least  some 
inflammatory  oedema  in  the  interstitial  tissue. 

Symptomatology. — The  onset  is  usually  sudden,  with  headache,  pain 
in  the  back,  nausea,  vomiting,  pallor  and  the  early  development  of  slight 
oedema.  Fever  is  slight  or  absent.  The  urine  is  scanty  and  may  at  first 
be  completely  suppressed;  the  specific  gravity  is  high;  it  contains  much 
albumen,  blood  and  casts.  Acute  uraemic  symptoms  occur  in  a  certain 
number  of  cases— vomiting,  mania,  convulsions  or  coma.  Although  always 
a  serious  disease,  there  is  a  natural  tendency  to  recovery  with  complete 
restoration  of  function  after  a  course  of  from  several  weeks  to  several  months. 

Treatment. — A  minimal  amount  of  work  should  be  put  upon  the  kidneys 
by  reducing  metaboHsm  and  body  waste,  and  utilizing  other  methods  of 
elimination.  The  patient  is  put  to  bed  on  a  diet  yielding  about  50  grams  of 
proteid  and  2000  or  2500  calories.  This  is  best  obtained  by  milk  and  cream, 
with  a  small  amount  of  cereal,  breadstufifs  and  sugar.  If  oedema  is  present 
the  amount  of  fluid  and  of  sodium  chloride  should  be  greatly  restricted. 
Free  catharsis  should  be  maintained.     Diuretics  may  be  used,  but  are  of 


248  SYSTEMIC   OCCUPATIONAL   DISEASES 

doubtful  value.     If  uraemia  threatens,  sweating  and  free  venesection  are 
indicated.     Iron  should  be  given  during  convalescence. 

Chronic  Interstitial  Nephritis. — This  is  the  more  common  form  of  renal 
disease  resulting  from  occupation,  and  is  met  with  among  workers  in  lead 
and  other  heavy  metals,  or  occurs  as  an  accompaniment  of  arteriosclerosis 
from  overstrain. 

Pathology. — The  kidneys  are  usually  small,  the  capsule  thickened  and 
adherent,  the  epithelium  degenerated,  the  vessels  sclerotic  and  there  is  a 
marked  overgrowth  of  the  interstitial  connective  tissue.  The  heart  is' 
always  hyper trophied  and  the  arteries  usually  sclerosed.  Anaemia  nearly 
always  develops  in  the  course  of  the  disease. 

Symptomatology. — The  disease  is  usually  insidious  in  its  onset,  and  is 
first  recognized  as  a  result  of  a  urinary  examination,  or  by  the  occurrence  of 
a  serious  compUcation.  Early  symptoms  are  failure  of  strength,  headache, 
dizziness,  sleeplessness,  loss  of  appetite  and  dyspepsia,  and  moderate  dyspnoea 
on  exertion.  The  urine  is  increased  in  quantity,  is  of  low  specific  gravity, 
contains  a  trace  of  albumen  and  a  few  casts.  Disturbances  of  vision  may 
occur,  with  retinal  hemorrhages  or  albuminuric  retinitis.  The  pulse  is 
tense  and  full  and  the  systolic  and  the  diastolic  blood  pressures  increased. 
The  later  developments  of  the  case  are  usually  those  of  chronic  urasmic 
poisoning,  nocturnal  dyspnoea,  with  Cheyne-Stokes  respiration,  uncontrollable 
vomiting,  local  palsies,  mania,  convulsions,  coma;  or  of  cardiac  decompensa- 
tion, described  above. 

Treatment. — Pathologically  the  disease  is  incurable,  but  much  may  be 
done  to  prevent  its  progress  and  keep  the  patient  in  a  fair  degree  of  health. 
The  causes  of  kidney  irritation  or  of  arterial  strain  should  be  obviated. 
This  usually  means  a  change  of  occupation,  with  the  adoption  of  one  that  is 
less  strenuous,  or  in  which  chronic  poisoning  from  any  source  may  be  avoided. 
The  diet  should  be  light  and  nourishing,  similar  to  that  recommended  for 
arteriosclerosis.  If  active  work  is  to  be  continued  70  to  80  grams  of  proteid  a 
day  may  be  allowed;  if  a  sedentary  life  is  adopted,  50  grams  is  sufficient. 
The  fluid  intake  should  be  restricted  to  about  2  quarts,  to  relieve  the  kidneys 
of  extra  work.  The  bowels  and  skin  require  careful  attention.  Sweating 
and  active  catharsis  may  be  called  for  later,  with  the  nitrites,  if  the  early 
symptoms  of  chronic  uraemia  supervene.  Iron  is  nearly  always  required 
for  the  anaemia,  and  digitalis  in  full  doses  for  the  later  cardiac  insufficiency 
tides  over  many  a  crisis. 


DIVISION  in 
Fatigue  and  Occupation.    Neuroses 

CHAPTER  I 
FATIGUE  AND  OCCUPATION 

BY  FREDERIC  S.  LEE,  Ph.D.,  New  York  City,  N.  Y. 

Fatigue  is  a  corporeal  condition  which  ought  to  be  taken  account  of  in 
all  human  activities,  and  especially  is  this  true  of  the  activities  of  industrial- 
ism.^-^^  In  the  now  prevalent  discussion  of  industrial  efficiency  fatigue  has 
remained  largely  in  the  background  and,  whenever  it  has  entered  into 
consideration,  what  has  been  written  about  it  has  too  often  revealed  an 
ignorance  of  physiological  knowledge.  In  its  relations  to  disease,  too, 
the  importance  of  fatigue  has  never  been  adequately  recognized,  and  here 
again  industrialism  seems  to  offer  many  examples  of  the  general  principles. 
Before  proceeding  to  discuss  these,  it  will  be  well  to  get  in  mind  a  clear  picture 
of  the  nature  of  fatigue. ^ 

Fatigue  in  the  individual  has  its  subjective  and  its  objective  aspects  and 
hence  may  be  considered  from  the  two  standpoints  of  the  psychical  and  the 
physical.  After  he  has  been  active  mentally  or  physically  the  average  man 
"feels"  tired;  that  is,  to  him  fatigue  is  a  matter  of  sensation,  and  his  sensa- 
tions are  the  sole  measure  of  his  weariness;  he  has  no  comprehension  of 
any  material  changes  in  his  body  w'hich  accompany  his  feelings.  Yet 
important  material  changes  have  occurred.  Many  of  them,  however,  are 
still  unknown  even  to  the  specialist  in  fatigue  and,  indeed,  both  the  psych- 
ical and  the  physical  aspects  of  the  subject  are  much  in  need  of  intensive 
investigation. 

Fatigue  in  the  usual  sense  of  the  word  may  be  defined  as  a  diminished 
capacity  for  work  which  is  the  result  of  previous  work.  This  final  clause 
imposes  upon  the  use  of  the  word  a  somewhat  too  narrow  restriction,  for 
diminished  capacity  for  work,  indistinguishable  from  that  due  to  previous 
work,  is  often  present  when  previous  activity  has  not  occurred.  Thus, 
disease  may  put  the  body  into  such  a  condition  that  its  working  power 
is  lessened;  lack  of  food  may  do  the  same;  the  excessive  use  of  one  set  of 
muscles  may  diminish  the  power  of  other  muscles  or  of  the  brain  to  work. 
These  cases  have  certain  causative  factors  in  common  and  it  is  often  con- 
venient to  use  the  word  "fatigue"  so  as  to  include  a  considerable  variety  of 

249 


250  FATIGUE    AND    OCCUPATION.      NEUROSES 

such  instances.     Thus  a  usage  of  the  word  sharply  limited  to  a  state  follow- 
ing work  is  not  desirable. 

Fatigue  of  Tissues. — Diminished  capacity  for  work  may  be  demonstrated 
very  clearly  by  a  single  muscle.^  If  the  muscle  of  an  animal,  such  as  a 
frog  or  a  cat,  be  removed  from  the  body  immediately  after  death,  be  attached 
to  a  weighted  recording  lever  which  writes  on  a  slowly  revolving  drum,  and 
be  stimulated  by  electric  shocks  at  regular  intervals,  a  graphic  record  may 


Fig.  6. — Series  of  contractions  of  a  frog's  sartorius  muscle,  excised  and  stimulated  at 
intervals  of  2}'^  seconds.  The  contractions  at  first  increase  in  extent,  this  stage  constituting 
the  treppe,  reach  a  maximum,  and  later  decrease,  this  stage  constituting  fatigue. 

be  made  of  the  resulting  contractions  as  a  series  of  vertical  lines  (Fig.  6)' 
The  contractions  at  first  increase  in  extent,  as  is  indicated  by  a  progressively 
increased  height  of  the  successive  lines.  This  is  followed  by  a  period  of 
only  slight  change  in  their  extent  and  later  by  a  progressive  decrease.  These 
three  phases  are  called  respectively  the  period  of  the  treppe,  or  staircase, 
the  period  of  maximum  contractions,  and  the  period  of  fatigue.  Such  a 
record  is  an  epitome  of  the  behavior  of  the  working  muscle  within  the  intact 


Fig.  7. — Series  of  contractions  of  the  two  excised  gastrocnemius  muscles  of  a  frog, 
lifting  equal  weights,  the  upper  stimulated  at  the  rate  of  20  times,  the  lower  at  the  rate  of 
45  times,  per  minute.     Note  the  earlier  fatigue  of  the  more  rapidly  working  muscle. 

living  body,  athough  in  the  latter  case  all  the  phases  of  the  action  are  greatly 
prolonged.  If  the  muscle  be  stimulated  more  rapidly  (Fig.  7),  or  be  made  to 
lift  a  heavier  weight  (Fig.  8),  fatigue  comes  on  more  rapidly.  If  at  any  stage 
in  the  fatigue  the  stimulation  be  stopped  and  the  muscle  be  allowed  to  rest, 
there  is  a  restoration  of  working  power  which  is  more  or  less  pronounced 
according  to  the  conditions  of  the  experiment.  If  a  circulation  of  blood 
or  other  appropriate  oxygenated  liquid  be  established  through  the  muscle, 


FATIGUE    AND    OCCUPATION 


251 


recovery  may  be  complete  (Fig.  9).  All  kinds  of  muscle  are  capable  of 
fatigue,  not  only  the  skeletal  muscles  of  the  limbs  and  the  trunk,  but  the 
muscle  of  the  heart  and  the  unstriated  muscle  of  the  other  viscera.  All  of 
the  phenomena  mentioned  have  their  counterpart  within  the  intact  living 
body,  whether  of  the  lower  animal  or  of  man. 

The  diminution  in  the  capacity  for  work  which  is  so  clear  in  the  fatigue 
of    muscle    has  been   demonstrated,   although  less  clearly,   by  laboratory 


■ 

mmm 

Fig.  8. — Series  of  contractions  of  the  two  excised  gastrocnemius  muscles  of  a  frog, 
stimulated  at  the  sam^  rate  of  27  times  per  minute,  the  upper  lifting  10  grams,  the  lower 
30  grams.     Note  the  earlier  fatigue  of  the  muscle  doing  the  more  work. 

experiments  on  certain  other  tissues  and  is  undoubtedly  characteristic  of  all 
living  substance.  Much  efiFort  has  been  expended  in  attempting  to  learn 
whether  nervous  tissue,  either  within  or  without  the  central  nervous  system, 
is  capable  of  fatigue.  This  effort  was  for  a  long  time  blocked  in  the  case  of 
nerves  themselves,  which  seem  to  exhibit  no  signs  whatever  of  fatigue  after 


Fig.  9. — Series  of  contractions  of  a  frog's  gastrocnemius  muscle  in  situ  with  the  circu- 
lation of  the  blood  undisturbed.  The  muscle  was  stimulated  for  g  minutes,  was  allowed 
to  rest  for  15  minutes  during  the  break  in  the  series,  and  was  then  stimulated  for  9  minutes. 
Note  the  recovery  from  fatigue  during  the  brief  rest. 

being  stimulated  for  even  many  hours.  More  recently  it  has  become  possible 
to  detect  a  decrease  in  their  electrical  current  of  action  and  their  irritability 
and  thus  a  diminished  capacity  for  work  after  nerves  have  conducted  nervous 
impulses  for  a  considerable  period  of  time.  It  is  not  at  all  certain,  however, 
that  this  occurs  in  the  intact  living  body,  where  nerves  seem  to  be  extra- 
ordinarily resistant  to  the  deleterious  results  of  previous  activity.  So 
within  the  brain  and  spinal  cord  it  has  been  difficult  to  demonstrate  fatigue,^ 


252  FATIGUE   AND   OCCUPATION.       NEUROSES 

and  the  idea  is  prevalent,  also  without  wholly  satisfactory  experimental 
evidence,  that  while  the  central  nervous  system  is  capable  of  fatigue  no  part 
of  the  nerve  cell,  or  neurone,  is  readily  fatiguable,  and  that  when  nervous 
fatigue  does  appear,  it  is  localized  primarily  in  the  synapses  or  semi-permeable 
membranes  at  the  junctions  between  successive  neurones. 

Chemical  Changes  in  Fatigue. — The  diminished  capacity  for  work  that 
appears  in  living  substance  engaged  in  activity  is  a  sequence  of  specific  chemical 
changes  that  occur  in  the  substance  and  are  a  part  of  its  metabolism.^ 
These  are  of  two  kinds:  First,  material  that  is  essential  to  activity  is  gradually 
used  up  and  thus  the  stock  of  available  material  becomes  gradually  exhausted; 
if  this  process  continues  without  new  material  being  supplied,  activity  must 
in  time  necessarily  cease.  Secondly,  there  appear  katabolites,  or  products 
of  activity;  these  are  poisonous  to  the  living  substance  and,  if  allowed  to 
accumulate,  gradually  diminish  its  working  power;  they  are  therefore  often 
called  "fatigue  substances."  These  two  processes  constitute  the  chemical 
causes  of  fatigue.  They  occur  simultaneously,  and  in  a  given  instance  it  is 
hardly  possible  to  determine  their  relative  importance  in  the  fatigue  process. 

As  to  the  identity  of  the  chemical  substances  involved,  the  evidence  is 
again  clearest  in  the  case  of  muscle.  When  muscle  contracts,  its  available 
oxygen  enters  into  chemical  combination  with  other  substances,  and  its 
glycogen,  which  is  the  chief  source  of  muscular  energy,  undergoes  disinte- 
gration. Unless  oxygen  and  glycogen  are  replaced  as  fast  as  they  are  used 
up,  the  muscle  in  time  ceases  to  contract.  Carbon  dioxide  and  lactic  acid 
are  produced  within  active  muscle  and,  unless  they  are  at  once  removed, 
they  react  deleteriously  on  the  muscle  cells,  diminish  their  irritability,  and 
contribute  to  their  fatigue.  When  in  small  quantity,  however,  carbon 
dioxide  and  lactic  acid  seem  to  act  in  the  opposite  way  and  temporarily  to 
increase  the  working  power  of  muscle.  To  this  latter  action  the  author^ 
has  ascribed  the  treppe,  or  preliminary  period  of  progressively  increased 
contractile  power,  which  is  present  in  the  early  stages  of  a  prolonged  period 
of  muscular  work.  That  other  metabolic  processes  in  the  muscle  share  in 
the  causation  of  fatigue  is  not  known  but  is  not  improbable.  An  endeavor^ 
has  been  made  experimentally  to  demonstrate  the  existence  in  fatigued 
muscles  of  a  specific  toxin  of  fatigue,  resembling  in  various  properties 
bacterial  toxins,  and  although  it  may  be  true,  as  claimed,  that  the  extract 
of  fatigued  muscles  contains  material  which  when  injected  into  animals 
seems  to  produce  a  condition  of  fatigue,  the  identity  of  a  specific  toxin  is 
not  clearly  established.  The  relations  between  fatigue  and  metabolism  in 
other  tissues  than  muscle  are  not  yet  ielucidated.  Diminution  of  oxygen 
and  increase  of  carbon  dioxide  can  of  course  diminish  the  working  power  of 
all  living  tissues.  It  is  conceivable  that  any  katabolic  process  prolonged 
without  corresponding  anabolism  may  in  time  diminish  the  working  power 
of  the  tissue  involved,  but  the  whole  subject  of  metaboHsm  in  fatigue  is 
much  in  need  of  investigation. 


FATIGDE   AND   OCCUPATION  253 

Fatigue  in  the  Human  Body. — When  we  turn  from  the  fatigue  of  specific 
tissues  to  the  phenomena  of  fatigue  in  a  complex  organism  Hke  the  human 
body,  the  problem  becomes  much  more  difficult.  (^Here  the  tissues  do  not 
act  separately;  the  excessive  work  of  one  increases  the  work  of  others. 
Contracting  voluntary  muscles  must  be  directed  by  an  active  nervous  system, 
and  they  demand  more  work  by  the  heart  and  the  respiratory  organs  and 
induce  more  secretion  by  the  various  glands.  All  of  these  actions  in  turn 
involve  the  nervous  system  in  greater  activity.  Drain  upon  a  store  of 
metabolic  material  in  one  organ  is  followed  by  a  call  for  a  supply  elsewhere 
in  the  body.  Moreover,  if  a  deleterious  katabolic  substance  is  produced  in 
quantity  by  one  organ  it  passes  in  circulating  blood  and  lymph  throughout 
the  body,  and  may  diminish  the  working  capacity  of  other  organs  or  tissues. 
Injthese  ways  fatigue  of  one  part  of  the  body  may  induce  the  phenomena  of 
fatigue  in  other  parts— local  fatigue  may  result  in  general  fatigue.  The 
exercisF^  one  set  of  muscles,  for  example,  will  fatigue  most  those  muscles 
and  the  corresponding  parts  of  the  brain  and  spinal  cord,  but  it  will  result 
also  in  some  degree  of  fatigue  in  other  parts  of  the  body.  A  person  who  has 
worked  sufficiently  hard  to  tire  his  muscles  mayhave  a  tired  brain  as  well, 
and  the  exhausted  brain  worker  is  in  no  condition  for  performing  hard 
physical  labor.  A  change  of  work  is  often  beneficial  as  a  temporary  expedient 
to  relieve  a  part  of  the  body  that  is  in  danger  of  becoming  exhausted, 
but  there  are  limits  to  the  possiblity  of  such  benefits,  and  it  ought  always  to 
be  borne  in  mind  that  excessive  work  by  one  part  means  a  certain  degree 
of  fatigue  for  all  parts. 

It  is  now  generally  conceded  that,  contrary  to  popular  belief,  sensations 
of  fatigue  are  no  measure  of  diminished  capacity  for  work.  It  has  been 
demonstrated  by  careful  laboratory  tests  that  a  given  task  may  be  performed 
as  effectively  and  as  readily  whether  the  individual  feels  fresh  or  tired. 
Thus,  a  student,  although  feeling  used  up  and  incapable  of  further  work, 
may  be  able  to  solve  arithmetical  problems  just  as  quickly  and  correctly  at 
the  end  of  a  series  of  such  tasks  extending  over  many  hours  as  at  the  beginning. 
A  feeling  of  fatigue  often  may  induce  a  disincHnation  to  work  and  even  a 
powerful  aversion  toward  it,  and  this  may  diminish  the  amount  of  work  ac- 
complished, although  at  the  same  time  not  decreasing  capacity.  A  slight 
change  in  one's  mental  state  often  makes  a  great  difference  in  achievement. 
Soldiers  can  march  farther  and  with  less  feeling  of  fatigue  when  music  ac- 
companies them.  Ayres^  found  that  in  a  6-day  bicycle  race  the  average 
number  of  miles  ridden  per  hour  on  one  of  the  days  of  observation  was  i8.8 
with  no  music,  and  21  when  the  band  played. 

Recovery  from  Fatigue. — Comparatively  little  is  known  of  the  details 
of  the  process  of  recovery  from  fatigue.  fAdrenin,  the  internal  secretion  of 
the  adrenal  bodies,  when  administered  to  a  fatigued  muscle  appears  to  have 
a  powerful  effect  in  increasing  its  irritabiHty  and  its  contractile  power.^ 
Whether  it  does  this  by  a  direct  action  on  the  muscle  substance  or  by  neu- 


254 


FATIGUE   AND    OCCUPATION.       NEUROSES 


tralizing  or  destroying  the  toxic  fatigue  substances  is  not  clear.  Nor  is  it 
clear  whether  it  acts  constantly  or  only  in  emergencies.  Some  investigators' 
have  claimed  the  discovery  of  a  specific  antitoxin  of  fatigue,  but  the  existence 
of  such  a  body  is  doubtful.  It  is  obvious  that  rest  brings  recuperation. 
During  rest  there  is  an  opportunity  for  the  excess  of  carbon  dioxide,  lactic 
acid,  and  whatever  other  fatigue  substances  may  be  present,  to  be  eliminated 
from  the  fatigued  tissues  and  from  the  body.  The  carbon  dioxide  is  passed 
out  of  the  body  through  the  lungs,  while  the  other  fatigue  substances  prob- 
ably either  pass  out  unchanged  in  the  urine  or  are  broken  down  into  simpler 
substances  before  being  discharged.  At  the  same  time  rest  gives  an  op- 
portunity for  the  rebuilding  within  thecells  of  the  substances  that  are 
necessary  to  further  activity. 

Tests  for  Fatigue. — Much  ingenuity  and  time  have  been  expended  by 
investigators  in  efforts  to  discover  reliable  objective  signs  of  fatigue  in  human 
beings  and    to  devise  ready  methods  of    demonstrating  them.     Many  of 


Fig.  io. — Series  of  voluntary  contractions  of  the  flexor  muscles  of  the  middle  finger 
lifting  a  weight  of  3  kilograms.     Note  the  progressive  fatigue,     {From  Mosso.) 

these  efforts  have  failed.  One  of  the  earliest  contributions  was  that  of  the 
ergograph  of  Mosso^  which  records  the  contractions  of  a  certain  set  of  muscles, 
such  as  those  involved  in  the  bending  of  a  finger,  when  stimulated  at  regular 
intervals,  either  by  the  will  through  the  nervous  system  or  by  electric  shocks 
directly  applied  to  the  muscles,  and  when  made  to  lift  a  given  weight  (Fig. 
10).  The  ergograph  was  believed  to  afford  an  exact  method,  easily  applied, 
by  which  bodily  fatigue  can  be  readily  demonstrated,  and  it  was  extensively 
used  to  obtain  data  for  the  formulation  of  the  laws  of  human  fatigue.  It 
has  now  been  shown,  however,  that  ergographic  records  are  really  significant 
only  when  made  by  a  trained  subject.  Even  then  the  fall  in  the  curve  as  the 
work  progresses  is  no  real  measure  of  ultimate  fatigue  of  either  the  muscles 
or  the  nerve  tissues.  It  is  doubtful  whether  it  reveals  more  than  a  tem- 
porary lack  of  oxygen  in  the  neuromuscular  mechanism.  A  slight  diminution 
in  the  weight  to  be  lifted  often  shows  that  the  mechanism  is  in  good  working 
condition  and  is  capable  of  working  for  an  indefinite  period.} 


FATIGUE   AND    OCCUPATION  25$ 

Various  so-called  mental  tests,  such  as  speed  and  accuracy  in  the  per- 
formance of  arithmetical  problems,  the  speed  and  accuracy  of  perception  and 
of  certain  movements,  attention  tests,  memory  tests,  the  estimate  of  time, 
the  degree  of  sensitivity  of  the  skin  to  stimuli  variously  applied,  and  others, 
have  all  contributed  valuable  data,^  yet  they  require  intelligent  trained  sub- 
jects under  exact  experimental  conditions  and  the  expenditure  of  consid- 
erable time,  and  even  when  all  the  requirements  for  accurate  observation 
are  provided  they  cannot  be  relied  on  to  reveal  unerring  signs  of  fatigue. 

The  production  of  fatigue  substances,  except  carbon  dioxide,  while  un- 
doubted, cannot  be  readily  demonstrated  in  the  living  man  by  our  present 
methods.  It  is  claimed  that  in  the  urine  of  fatigue  there  is  less  nitrogen 
combined  in  other  substances  than  in  urea.  Although  the  alkalinity  of 
the  blood  and  the  amount  of  sugar  present  in  it  are  said  to  be  decreased 
in  fatigue,  such  chemical  tests  are  hardly  practicable  in  the  human 
body  as  routine  procedures.  No  direct  relation  between  bodily  tempe;*a- 
ture  and  fatigue  has  been  observed.  The  distribution  of  the  blood  in 
the  body  is  probably  altered  by  a  long-continued  fatiguing  task:  by  the 
end  of  a  hard  day's  work,  either  mental  or  physical,  much  blood  has 
probably  been  drained  away  into  the  limbs  and  the  brain  is  left  relatively 
anaemic,  this  doubtless  accounting  in  part  for  the  feeling  of  sleepiness  that 
is  then  present.  Preliminary  experiments  by  the  author  and  others  seem 
to  make  it  possible  that  a  careful  study  and  evaluation  of  vascular  conditions, 
such  as  blood  pressure  and  heart  rate,  may  reveal  reliable  objective  signs  of 
the  presence  of  fatigue.  But  until  adequate  and  readily  applied  methods  of 
quantitative  measurement  and  accurate  locahzation  in  the  intact  individual 
can  be  devised,  fatigue  as  a  topic  of  exact  science  must  remain  in  an  unsatis- 
factory state.  The  lack  of  such  methods  is  especially  regrettable  in  the  field 
of  industrial  occupations.  Here  our  conclusions  as  to  the  presence  and  the 
degree  of  fatigue  must  for  the  present  be  largely  a  matter  of  indirect  inference 
rather  than  of  direct  demonstration.^^ 

(  Fatigue  and  Disease. — The  connection  between  fatigue  and  disease  is 
probably  much  more  frequent  and  close  than  is  usually  recognized.  To 
disease  fatigue  stands  in  the  relation  of  both  cause  and  effect.  That  it  may 
be  a  factor  in  causing  disease  is,  indeed,  often  believed,  and  this  belief  is 
justified  by  laboratory  experiments.  Thus,  it  has  been  shown  experimen- 
tally that  of  two  groups  of  animals,  the  qne  resting  and  the  other  fatigued  by 
muscular  work  and  both  inoculated  by  pathogenic  bacteria,  the  fatigued 
animals  exhibit  a  fall  of  the  opsonic  index  and  succumb  to  the  disease  in 
larger  numbers.^  This  may  best  be  interpreted  as  indicating  that  the 
resistance  of  the  body  to  the  action  of  bacteria  is  diminished  by  the  metabolic 
changes  involved  in  the  fatigue  processes.  If  this  is  true  of  one  species  of 
bacterium  it  is  probably  true  of  others,  and  from  the  prevalence  of  the 
infectious  diseases  in  the  life  of  man  it  is  obvious  how  important  is  the 
matter  of  avoiding  undue  fatigue.  /  Fisher^  has  written  graphically:  "The 


256  FATIGUE   AND   OCCUPATION.      NEUROSES 

typical  succession  of  events  is  first  fatigue,  then  colds,  then  tuberculosis, 
then  death.     Prevention,  to  be  effective,  must  begin  at  the  beginning." 

Outside  the  realm  of  infections,  fatigue  as  a  causative  factor  in  disease  is 
perhaps  most  obvious  in  neurasthenia.  The  most  common  single  precedent 
of  this  form  of  neurosis  is  excessive  activity  of  the  nervous  system.  Con- 
tinued muscular  fatigue,  if  it  is  without  accompanying  excessive  excitation 
of  the  nervous  system,  probably  cannot  induce  neurasthenia;  the  nervous 
system  is  the  primary  seat  of  the  preceding  fatigue  process.  There  are,  of 
course,  many  contributing  causes,  but  overwork,  overpressure,  overstrain  are 
the  unavoidable  precedent  of  the  nervous  breakdown. 

The  immediate  causative  relation  of  fatigue  to  other  diseases  than 
those  mentioned  is  neither  so  obvious  nor  so  clearly  established,  but  it  is 
probable.  Fatigue  in  a  normal  degree  is  a  harmless,  even  a  healthful,  phenome- 
non— in  its  essentials  metabolic — which  involves  a  physiological  depression 
of  the  bodily  functions  and  induces  its  own  termination  and  a  return  to  the 
former  capacity  for  work,  but  it  can  easily  be  carried  too  far;  |destruction  of 
cellular  material  and  the  accumulation  of  toxic  katabolic  substances  unwisely 
persisted  in  without  adequate  opportunities  for  recuperation  can  proceed 
to  a  pathological  degree  and  interfere  profoundly  with  the  normal  metabolic 
processes  of  the  organism.  Thus  the  foundation  of  profound  diseased 
conditions  may  be  laid. 

That  fatigue,  or  at  least  proneness  to  fatigue,  is  an  effect  of  disease  is  too 
obvious  to  require  discussion;  diminished  capacity  for  work  is  the  one  almost 
universal  accompaniment  of  diseases  that  involve  alterations  of  general  met- 
abolism, such  as  infections,  febrile  diseases,  and  diabetes.  Here  we  find  the 
two  general  metabolic  processes  that  characterize  fatigue  even  more  promi- 
nent than  in  normal  states.  The  loss  of  substances  that  are  essential  to  ac- 
tivity is  well  illustrated  by  the  destructive  metabolism-ef  febrile  diseases 
and  the  excretion  of  sugar  in  diabetes  mellitus.  To  the  normal  fatigue  sub- 
stances, which  may  or  may  not  be  present  in  disease  in  abnormal  amounts, 
there  must  here  be  added  a  considerable  number  of  other  toxic  substances 
which  from  their  depressing  action  may  not  inappropriately  be  called  "patho- 
logical fatigue  substances."  This  group  includes  probably  the  whole  range 
of  bacterial  toxins  and  a  considerable  number  of  intermediate  metabolic 
products  derived  from  the  body's  own  cells.  Whether  in  perverted  met- 
abolism intermediate  metabolic  products  that  are  new  to  the  organism  are 
formed,  or  whether  the  change  consists  in  an  increase  in  quantity  of  normal 
metabolites,  are  questions  not  yet  settled  and  need  not  be  discussed  here. 
Whatever  their  origin,  examples  of  pathological  fatigue  substances  are 
oxybutyric  acid,  which  is  common  in  diabetes  mellitus,  and  indol,  which  is 
common  in  intestinal  putrefaction.  These  substances  are  known  to  be  de- 
pressing to  living  tissues,^"^  and  whenever  they  are  present  in  quantity  in  the 
living  body,  fatigue  is  a  prominent 'symptom.  Further  research  will,  with- 
out doubt,  reveal  the  depressant  action  of  other  products  of  pathological 


FATIGUE    AND    OCCUPATION 


257 


metabolism,  especially  the  acids  occurring  in  acid  intoxications.  Here  is  a 
wide  field  for  research.  Research  is  much  needed  also  in  such  conditions  as 
neurasthenia,  myasthenia  gravis,  and  various  other  diseases  which  are  char- 
acterized by  excessive  susceptibility  to  fatigue.  In  these  conditions  it  is 
justly  conceivable,  but  not  proved,  that  faulty  metabohsm,  resulting  in  the 
occurrence  of  pathologica4  fatigue  substances,  is  responsible  for  the  charac- 
teristic symptoms. 

("^ Fatigue  and  Industrial  Output. — In  modern  industry  fatigue  plays  a  role 
of  prominence  and  is  capable  of  demonstration  in  various  ways.  In  the  first 
place,  it  diminishes  the  output  of  the  worker.  An  Itahan  physiologist, 
Pieraccini,!^  has  made  a  study  of  the  amount  of  work  performed  at  different 
hours  of  the  day  by  several  manual  workers,  such  as  type-setters,  stone- 


FiG.  II. — The  distribution  during  the  working  day  of  the  total  output  of  six  typesetters 
working  at  piece  rates.  The  number  of  lines  set  during  each  hour  was  as  follows:  8-9, 
121;  9-10,  151;  lo-ii,  130;  11-12,  125;  12-2,  rest  and  lunch;  2-3,  142;  3-4  124;  4-5,  96. 
{After  Pieraccini.) 

cutters,  nail-makers,  diggers  and  bullet-makers,  and  has  found  that  it 
increases  rapidly  during  the  early  part  of  the  forenoon,  declines  toward  the 
noon  hour,  increases  again  to  a  lesser  maxiriiurn  after  luncheon,  and  then 
rapidly  falls  off  to  a  low  minimum  at  the  end  of  the  day's  work  (Fig.  11). 
The  total  output  of  the  afternoon  is  always  less  than  that  of  the  forenoon, 
and  the  quality  of  the  afternoon  work,  as  measured  by  the  number  of  errors, 
is  poorer.^  From  tlie  study  of  a  variety  of  industries  the  Committee  of  the 
British  Association^  summarizes  the  output  of  the  successive  5  hours  of 
a  spell  of  work  as  "smfcll,  very  great,  great,  fair,  small."  Roth^^  reports 
that  in  a  large  rolling  and  steel  mill  57.5  per  cent,  of  the  output  was  produced 
during  the  first  half  and  42.5  per  cent,  during  the  second  half  of  the  shift. 
This  general  result  has  its  counterpart  in  the  paradox  that  diminishing  the 
hours  of  labor  increases  the  total  output,  a  fact  that  has  been  demonstrated 
often  enough  to  be  accepted  as  true  within  reasonable  limits.  Industrial 
17 


258  FATIGUE    AND    OCCUPATIOX.       NEUROSES 

fatigue  is  also  shown  in  an  inferior  output  toward  the  end  of  a  long  working 
day  and  even  on  the  succeeding  day,  facts  that  are  abundantly  attested  by 
experience. 

Fatigue  and  Health  of  Industrial  Workers. — One  of  the  most  striking 
evidences  of  the  existence  of  fatigue  and  its  seriousness  in  industrial  work  is 
found  in  a  consideration  of  the  health  of  workers.  Here  we  must  distinguish 
between  localized  and  general  affections.  Localized  affections  comprise 
those  in  which  one  part  of  the  body,  such  as  a  group  of  muscles  with  their 
nervous  connections,  is  overstrained  by  long-continued  use.  Here  are  to 
be  grouped  the  fatigue  neuroses,  such  as  writers'  cramp,  telegraphers'  cramp, 
and  the  various  other  spasmodic  muscular  conditions  that  occur  in  vioUn 
and  piano  players,  seamstresses,  shoemakers,  hammermen,  and  others,  as 
well  as  miners'  nystagmus  and  the  professional  torticollis  of  tailors  and 
cobblers.  The  seat  of  these  pathological  conditions  is  probably  the  central 
nervous  system;  they  have,  however,  not  yet  been  critically  analyzed  suf- 
ficiently from  the  physiological  standpoint,  and  their  real  nature  is  there- 
fore unknown.  The  ascription  to  fatigue  as  the  causative  agent  of  the  more 
general  diseases  from  which  industrial  workers  suffer  is  not  so  clear  as  with 
the  localized  affections.  It  is  doubtful,  f6r  example,  whether  the  proneness 
of  locomotive  engineers  to  diabetes  is  rigTitly  to  be  attributed,  as  has  been 
done,  to  the  nervous  strain  of  their  work.  With  nervous  disorders  and  es- 
pecially neurasthenia,  how^ever,  the  connection  seems  quite  evident.  There 
can  be  no  question  that  this  state  of  chronic  generalized  fatigue,  which 
has  usually  been  supposed  to  be  pecuUar  to  professional  men,  men  of  large 
affairs  and  the  wealthy  unemployed,  is  often  directly  the  sequel  of  the 
cumulative  fatigue  of  the  long-continued,  monotonous,  wearing  labor  of 
industrial  workers.  There  is  a  general  consensus  of  opinion  among  those 
best  fitted  to  know  that  in  recent  years  there  has  been  a  marked  increase 
of  neurasthenia  among  working  people,  and  that  this  is  due  largely  to  the 
overstrain  of  their  occupations.  Leubuscher  and  Bibrowicz^^  showed  that 
at  the  large  industrial  sanitoria  at  Giitergotz  and  Beelitz  in  Germany  26 
per  cent,  of  the  patients  were  neurasthenics,  and  the  percentage  of  such 
cases  for  individual  years  rose  from  18  in  1897  to  about  40  in  1904  and  1905. 
Some  of  these  cases  were  classified  according  to  occupation  as  follows: 

Type-setters 15-75  per  cent. 

Carpenters 9 .  45  per  cent. 

Locksmiths 5 .  00  per  cent. 

Mechanics i .  90  per  cent. 

In  a  ^tudy  of  200  cases  of  neurasthenia  and  hysteria  in  the  Industrial  Sana- 
torium at  Zehlendorf,  Schonhals^''  found  the  distribution  between  skilled 
and  unskilled  workers  to  be  as  follows: 

Artisans,  highly  skilled,  57  per  cent.  \ 

f    1  -11    .  *    r  74  per  cent. 

_  ,         ,         J  skilled,  17  per  cent. 

General  workers  <         ,  •,,    ,    \^ 

[  unskilled,  26  per  cent. 


FATIGUE    AND    OCCUPATION 


259 


A  marked' percentage  of  these  workers  were  engaged  in  factories,  where 
the  strain  of  work  is  apt  to  be  great.  Cardiac  disorders  of  nervous  origin  are 
common  among  working  people.  Roth^-  has  pointed  out  the  prevalence 
of  anaemia  among  young  women  workers,  especially  those  in  textile  factories, 
shop-girls,  sewing  women,  and  maids  in  hotels  and  public  houses,  among  all 
of  whom  overwork  is  common. 

Fatigue  and  Borderland  of  Illness. — Even  where  diminution  of  output 
is  not  present  and  where  specific  diseases  cannot  be  traced  directly  to  the 
fatigue  of  labor  it  is  undoubted  that  industrial  overwork  often  occurs  and 
puts  the  worker  into  a  physical  condition,  at  present  difficult  to  recognize  by 
any  specific  test,  wherein  his  physiological  mechanism  is  in  a  state  of  de- 
pression and  ready  to  fall  a  prey  to  specific  maladies.  Treves^^  speaks 
of  this  as  not  presenting  "a  well-defined  morbid  picture;  but  it  is  a  slow 
deviation,  often  obscured  by  its  very  slowness,  and  predisposing  to  illness 
of  any  nature;  it  is  the  borderland  of  illness."  The  future  careful  study  of 
individuals  will  doubtless  make  this  condition  more  precise. 

/  Characteristics  of  Modem  Industry. — It  is  a  common  belief  that  fatigue 
aAd  its  resulting  evils  are  relatively  more  common  among  industrial  workers 
in  recent  than  in  earlier  times.  Notwithstanding  the  many  evils  of  the 
earher  human  slavery,  now  happily  nearly  extinct  throughout  the  world, 
this  belief  is  probably  in  the  main  correct.  Greater  fatigue  is  to  be  expected 
from  the  specific  characteristics  of  modern  industry.  While  these  differ 
in  detail  in  different  industries  they  frequently  include  the  following:  The 
great  division  of  labor  and  the  consequent  specialization  of  the  work  of  each 
individual,  the  speed  of  the  work,  certain  other  factors  of  the  work,  the 
imposition  of  long  working  periods  and  of  'overtime  work,  the  introduction 
of  piecework,  and  the  crowding  together  of  large  numbers  of  human  beings 
within  confined  spaces  often  poorly  ventilated.  These  will  now  be  con- 
sidered in  detail.  ^ 

Specialization  and  Speed  of  Work.^'  ^* — A  pronounced  feature  of  modern 
industrialism  is  the  great  division  of  labor  among  the  workers  and  the 
limitation  of  the  task  of  each  to  a  specific  procedure.  Wl^ile  certain  kinds 
of  work  still  require  the  expenditure  of  much  muscular  force  by  the  worker, 
the  introduction  of  machinery  has  tended  in  gener3,l  to  diminish  muscular 
effort.  It  has,  however,  been  replaced  by  a  new  element  which  is  no  less 
fatiguing,  namely,  speed.  Thus,  in  the  making  of  hinges  a  woman  lifts  a 
half-formed  hinge,  places  it  in  the  bending  machine  and  quickly  withdraws 
her  hand,  and  repeats  this  series  of  movements  at  the  rate  of  50  times  a 
minute,  or  30,000  times  a  day.  The  tops  of  tin  cans  are  cut  by  pressing 
the  lever  of  a  foot  press  40  times  a  minute,  24,000  times  a  day.  In  the  tele- 
phone service  an  operator  can  receive,  answer  and  make  the  proper  con- 
nections for  from  200  to  300  calls  in  an  hour;  in  weaving  one  woman  must 
supervise  16  to  24  looms,  ever  watchful  that  they  are  running  properly; 
in  sewing  a  single  girl  watches  intently  the  12  jumping  needles  of  her  power 


26o  FATIGUE    AND    OCCUPATION.    NEUROSES 

machine;  in  the  making  of  women's  clothing  by  modern  machinery  one 
operator  in  an  hour  will  tuck  250  yards  of  lawn,  another  will  hem  400  yards 
of  voile,  another  will  make  1000  buttonholes,  and  still  another  will  sew  on 
800  buttons;  in  the  manufacture  of  candy  one  employee  will  wrap  9000 
caramels  in  a  day;  and  in  a  cigar  factory  one  man  will  bunch  2000  stogies. 
An  expert  can  insert  in  one  day  the  eyelets  into  4000  shoes;  another  can  trim 
the  superfluous  leather  from  the  uppers  of  5200  shoes.  A  machine-made  shoe 
in  the  process  of  manufacture  is  said  to  pass  through  the  hands  of  no  less 
than  100  workers.  A  worker  doing  one  thing  does  nothing  else,  that  is, 
his  main  activities  are  limited  to  a  small  part  of  his  body,  to  a  restricted 
neuromuscular  mechanism,  which  undergoes  a  rapid  rhythmic  exercise. 
In  some  cases  this  exercise  becomes  hardly  more  than  a  series  of  exactly 
similar  unconscious  reflex  actions;  in  others  it  demands  the  aid  of  an  acutely 
attentive  consciousness.  The  danger  lies  in  the  pace  becoming  so  rapid  that 
there  is  httle  opportunity,  such  as  usually  exists  with  the  rhythmically  beat- 
ing heart,  for  recuperation  between  successive  discharges  of  energy.  At 
the  end  of  the  day's  work,  therefore,  the  physiological  mechanism  involved 
is  too  often  near  exhaustion  and  even  the  rest  of  the  body  may  suflfer 
likewise. 

We  have  here,  indeed,  a  condition  strikingly  like  that  of  the  single  excised 
muscle  of  the  familiar  laboratory  experiment  (Fig.  6) :  With  the  excised 
muscle  the  stimuli  are  electric  shocks  regularly  and  rapidly  repeated;  with  the 
industrial  worker  there  is  a  restricted  group  of  muscles  stimulated  rhyth- 
mically from  a  particular  part  of  the  nervous  system.  In  both  cases 
necessary  metabolic  material  is  consumed  and  fatigue  substances  are  pro- 
duced. With  the  excised  bloodless  muscle  there  is  no  replacement  of  the 
one  or  the  removal  of  the  other,  and  the  stage  of  exhaustion  is  quickly 
reached;  with  the  human  muscles  and  the  associated  nervous  tissues  fuel 
and  oxygen  are  brought  and  wastes  are  removed  by  the  blood,' but  with 
the  great  speed  of  stimulation  katabolism  is  pretty  sure  to  exceed  anabolism, 
and  thus  favorable  conditions  are  provided  for  the  production  of  pronounced 
fatigue  in  the  parts  involved  and  a  lesser  degree  of  fatigue  in  other  parts 
of  the  body.     The  lesson  of  Fig.  7  is  here  directly  applicable. 

Certain  Other  Factors  of  Work. — Besides  speed  there  are  certain  other 
features  of  industrial  work  which  contribute  to  fatigue.  This  is  obvious,  for 
example,  in  the  lifting  of  heavy  weights.  Fig.  8  shows  clearly  that  the 
heavier  the  load  the  earlier  is  the  muscle  exhausted.  Processes  that  involve 
the  jarring  of  the  body  are  probably  also  similarly  detrimental.  This  is  a 
feature  of  the  action  of  certain  kinds  of  heavy  machinery  and  especially  of 
pneumatic  tools.  The  excessive  noise  of  some  kinds  of  machinery,  es- 
pecially looms,  acts  to  distract  the  attention  and  thus  makes  more  wearing 
the  specific  task  of  the  worker.  This  is  doubtless  a  greater  factor  in  the 
production  of  fatigue  when  the  noise  is  variable  in  intensity  and  uncertain 
in  its  onset.     It  is  conceivable  that  a  worker  mav  become  accustomed  to 


FATIGUE    AND    OCCUPATION 


261 


and  learn  to  neglect  a  constant  hum  or  roar  in  his  environment.  Faulty  or 
strained  postures  of  the  body,  necessitated  by  the  holding  of  tools  in  certain 
positions  or  the  tending  of  machines,  are  a  fruitful  and  often  unnecessary 
source  of  bodily  fatigue. 

Length  of  Working  Period. — The  tendency  of  modern  industrialism, 
actuated  by  commercial  motives,  has.  been  to  demand  of  laborers  the  longest 
possible  working  period.  More  than  a  century  ago  humanitarianism,  urged 
by  the  evils  of  excessive  labor,  began  to  protest  against  this  unbridled  over- 
taxing of  human  beings  and  undertook  to  secure  legal  limits  to  the  length 
of  the  working  day.  The  passage  by  the  British  Parliament  in  1802  of 
the  Health  and  Morals  of  Apprentices  Act  marks  the  beginning  of  such 
legislation.  The  science  of  physiology  can  now  provide  even  stronger 
arguments  for  reducing  the  hours  of  labor  than  can  humanitarianism,  and 
in  recent  years  there  is  here  a  tendency  to  utilize  physiological  knowledge. 
That  there  is  still  great  diversity  of  custom  as  to  duration  of  labor  in 
different  countries  and  in  different  trades  is  shown  by  the  following  tables: 

Relative  Percentage  of  Weekly  Hours  of  Labor  in  Different  Countries,  Those 
OF  the  United  States  being  Taken  as  100" 

United  States 100 

England  and  Wales 104 

Germany /. 115 

France 121 

Belgium 126 


Weekly  Hours  of  Labor  and  Percentage  of  Laborers  in  Industries  in  the  United 
States  Employing  25,000  or  More  Persons'** 


48  hours    Betweenj 

and       ,    48  apd    ,  S4  hours 
under     j  54  hours 


Between  \  .  Between 

54  and    '  60  hours  i    60  and 
60  hours  '  72  hours 


72  hours 
and  over 


Cotton 1  O.I 

Hosiery  and  knit  goods.  .  .  .  j  0.7 

Woolen  goods \  0.2 

Silk '  0.1 

Cordage  and  twine 0.5 

Dyeing  and  twisting  textiles  o .  2 

Iron  and  steel  blast  furnaces 

Steel  works  and  rolling  mills  7 . 6 

Electric  machinery 1.3 

Shipbuilding 9.5 

Agricultural  implements.. . .  0.9 

Slaughtering 1  5.5 

Flour  and  grist  mills j  8.6 

Canning  and  preserving. . . . !  4.4 

Lumber 1  3.4 

Musical  instruments 3.3 

*  Negligible. 


0.8 
2.6 
0.6 

2-3 

0.8 

2-5 


1-7 
16.0 
6.6 
4.0 
4.6 

i-S 
2.  2 

2-5 

6.7 


O.  I 

3-7 
0.7 

2-3 

9-3 
0.9 


10. o 
24.0 
24.4 

8.1 
II. 7 

6.6 

S-i 
6.0 

45-7 


50-4 
50.6 

71 .0 
82.2 
63.0 
64.0 

o-S 

12. 1 

52.2 
24.8 

54-5 
4.8 
4.2 

7-7 
7.2 

159 


31-5 
38.6 
26.8 
13.0 

23-3 
28.7 

30 
34-2 

6.7 
34-7 
32.3 
72.  2 

48.3 
71.6 

67-5 
28.2 


17.0 

1  0 

I 

3.8 

0.6 

1 

... 

* 

2.6 

3.6 

10.6 

! 

86 

0 

12.6 

21 

1 

8 

* 

* 

0.3 

0.7 

II. 8 
4.8 


o-S 

18.9 

4.2 

03 


262 


FATIGUE    AND    OCCUPATION.       NEUROSES 


Weekly  Hours  of  Labor  and  Percextage  of  Laborers  in  Industries  in  the  United 
States  Employing  25,000  or  More  Persons. — {Continued) 


48  hours 

and 
under 


Between 
48  and 
S4  hours 


54  hours 


Between  I 
54  and   1  60  hours 
60  hours 


Between 
60  and 
72  hours 


72  hours 
and  over 


Coke 

Gas 

Steam  laundries 

Turpentine  and  rosin.  . . 

Boot  and  shoe 

Leather 

Paper  and  wood  pulp. . . 
Printing  and  publishing. 

Automobile 

Carriage  and  wagon.  .  .  . 

Glass 

Brick  and  tile 

Pottery,  etc 

Carpet  and  rug 


6.8 

1-3 
8.4 

37-4 
0.4 
0.9 
7-4 

53-7 
0.4 
4.6 

16. 5 
10.4 

11. 6 


1.2 

* 

15-8 
6.7 
3-3 
2.8 
8.0 

16.0 

3-0 

7.0 
24.1 

2.0 
10.  2 

0.5 


27.2 

3-0 
19.0 

2.6 
24.0 

7.0 

4.5 
18.3 
30.0 
16.7 
12.6 
12.2 
17.9 
21.3 


39-7 
15-6 
33-7 
49-8 
14.7 
49.2 
30.2 
4.2 
29.4 
39-7 
iS-6 
66.1 

39  I 
36.2 


133 

15-5 
0.5 

2-5 

o.  I 

* 

19.6 

O,  2 


0.5 

4-9 
2.6 

1-7 


II. 2 

57-6 

0.1 

0.4 


21.7 

0.1 

1.8 
* 

5-9 
0.6 
0.8 


*  Negligible. 

In  considering  the  above  table  it  should  be  borne  in  mind  that  48  hours 
of  weekly  labor  mean  customarily  a  working  day  of  8  hours  for  6  days 
in  the  week  and  a  day  of  rest  on  Sunday;  54  hours  mean  a  working 
day  of  9  hours  for  6  days  in  the  week,  60  hours  one  of  10  hours  for  6  days, 
and  72  hours  one  of  12  hours  for  6  days.  These  are  hours  of  actual  labor 
and  do  not  usually  include  the  period  of  luncheon,  e.xcept  where  the  72- 
hour  week  prevails. 

The  most  striking  instance  among  well-organized  modern  industries  of 
a  long  period  of  compulsory  labor  is  afforded  by  the  iron  and  steel  industry 
of  the  United  States.  In  1910  the  Department  of  Commerce  and  Labor^^ 
made  a  very  full  investigation  of  the  conditions  of  labor  in  iron  and  steel 
factories  and  found  that  of  the  172,671  employees  of  blast  furnaces,  steel 
works,  and  rolling  mills,  covered  by  the  report,  62.98  per  cent,  customarily 
worked  more  than  60  hours  per  week;  42.58  per  cent,  worked  72  hours  or  more 
per  week;  while  20.59  per  cent,  worked  84  hours  or  more.  A  weekly  labor  of 
72  hours  means  12  hours  every  day  except  Sunday,  while  one  of  84  hours 
means  12  hours  daily  including  Sunday.  The  luncheon  period  is  here  in- 
cluded, but  it  is  usually  brief  and  desultory.  The  customary  working  time 
of  29.28  per  cent,  of  the  employees  was  7  days.  Once  in  every  week  or  every  2 
weeks,  when  a  night  shift  was  changed  to  day  work  and  vice  versa,  one  shift 
remained  at  work  continuously  for  either  18  or  24  hours.  Since  the  above 
investigation  there  has  been  a  marked  diminution  of  the  proportion  of  em- 
ployees who  are  required  to  labor  every  day  in  the  week,  but  the  requirement 
of  72  hours  for  a  large  number  of  the  workers  still  holds. 

In  determining  the  proper  length  of  the  working  period  the  factor  that 


FATIGUE    AND    OCCUPATION  263 

should  be  considered  first  is  not  the  commercial  but  the  physiological  one. 
No  one,  except  in  rare  emergencies,  should  be  forced  by  his  employer  to  labor 
continuously  for  such  a  period  that  subsequent  time  allowed  for  rest  is  in- 
sufficient to  enable  him  to  recuperate  before  the  beginning  of  the  next  work- 
ing period.  Physiological  facts,  though  exact  data  are  here  meager,  leave  no 
doubt  about  the  necessity,  as  a  custom  for  most  individuals,  of  one  day's  rest 
or  change  of  occupation  in  every  7  days  if  one's  body  is  to  be  kept  in  an  effi- 
cient physiological  state.  The  proper  length  of  the  working  period  of  the 
other  6  days  ought  to  depend,  first,  upon  the  degree  of  fatigue  that  is  induced 
by  the  specific  labor.  Here  again  exact  studies  are  much  needed.  Different 
varieties  of  labor  undoubtedly  difier  greatly  as  to  their  fatiguing  power 
and  this  can  be  modified  by  many  things,  but  too  little  is  known  of  this^- 
Dififerent  individuals,  too,  differ  greatly  in  susceptibility  to  fatigue.  More- 
over, the  sociological  question,  is  a  legitimate  one,  namely:  What  pro- 
portion of  an  individual's  working  hours  ought  equitably  to  be  spent  in 
his  vocational  work?  A  customary  working  day  of  12  hours  can  hardly 
be  justified  on  either  physiological  or  sociological  grounds.  The  limit  in 
most  occupations  has,  therefore,  been  gradually  reduced,  and  the  present  goal 
of  most  employees  is  that  of  an  8-hour  day  and  a  44-hour  week,  which 
signifies  a  half-holiday  on  Saturday.  In  those  industries,  such  as  the  manu- 
facture of  certain  iron  and  steel  products,  where  it  is  claimed  that  continuous 
operation  of  a  plant  is  necessitated  by  the  nature  of  the  processes  involved, 
either  a  12-hour  or  an  8-hour  shift  would  seem,  if  the  claim  is  true,  to  be 
essential.  In  the  steel  industry  of  Great  Britain  the  shorter  working 
period  is  gradually  being  introduced.  In  the  United  States  movement  in 
the  direction  of  an  8-hour  day  has  been  hastened  by  the  adoption  of  such  a 
day  with  a  44-hour  week  for  all  employees  of  the  national  government. 

Where  there  has  been  an  intelligent  comparison  of  the  8-hour  and  a  longer 
working  period  in  actual  experience,  the  result  has  proved  satisfactory  and 
advantageous  to  both  employees  and  employers.  Thus,  the  Salford  Iron 
Works,  engaged  in  the  manufacture  of  machinery,  at  Manchester,  England, 
in  1893  reduced  the  hours  of  weekly  labor  of  its  employees  from  53  to  48, 
i.e.,  from  a  g-hour  to  an  8-hour  day,  and  made  a  careful  study  of  the  result. 
It  was  found  that  production,  instead  of  falling  off,  actually  increased. 
The  recent  reduction  in  the  steel  works  of  South  Wales  from  a  12-hour  to  an 
8-hour  shift  has  resulted,  so  far  as  the  figures  have  been  collated,  in  an 
average  increase  of  output  of  123^^  per  cent,  in  the  smelting  shops  and  223^^ 
per  cent,  in  the  bar  mills.  A  change  from  a  g-hour  to  an  8-hour  day  was 
made  in  igoo  by  the  Zeiss  Optical  Works  in  Jena,-°  also  with  an  increased 
output  in  the  lessened  time.  As  the  workers  there  were  pieceworkers,  there 
were  also  increased  earnings  on  their  part.  This  result  was  due,  not  to  a 
better  feehng  on  the  part  of  the  workers,  but  to  the  increased  speed  and  effort 
which  they  unconsciously  exerted.  This  resulted,  of  course,  in  increased 
fatigue  from  the  actual  work  of  production,  but,  on  the  other  hand,  the  shorter 


264  FATIGUE    AND    OCCUPATION.    NEUROSES 

working  period  insured  two  advantages,  namely:  lessened  "passive"  fatigue, 
as  Abbe  called  it,  that  is,  the  fatigue  of  constant  attention,  fixed  attitude,  and 
exposure  to  noise  and  confusion;  and  a  longer  period  for  recuperation.  Abbe 
believed  that  for  three-fourths  of  the  industrial  workers  of  Germany  8  hours 
was  sufficiently  long  to  reach  their  maximum  of  daily  production. 

The  fatigue  of  the  regular  working  period  is  added  to  by  the  not  infre- 
quent practice  of  requiring  employees  to  work  overtime  in  periods  of  emer-  ■ 
gency.  In  the  canning  industry,  for  example,  the  demands  of  perishable  fruit 
or  vegetables  often  induce  employers  to  call  back  their  staff  for  long  evenings 
of  work  after  the  usual  day  of  labor  has  ended.  The  Christmas  "rush" 
season  in  shops  is  a  time  of  overfatigue  for  many  salesmen.  Overtime  work 
is  always  apt  to  be  strenuous,  and  the  fatigue  that  results  from  it  is  probably 
relatively  less  easily  compensated  for  than  is  that  of  the  usual  day's  labor.) 

Whether  the  universal  adoption  of  a  rigid  8-hour  work  day  for  all  in- 
dustries would  ultimately  be  best  for  society  and  the  individual  is  doubtful. 
In  the  ideal  scheme  of  labor  it  would  seem  that  no  person  ought  to  be  denied 
the  pursuit  of  his  vocation  for  a  longer  period  than  8  hours  in  24,  provided 
the  longer  labor  is  not  detrimental  to  him  or  to  society.  The  leaders  in  the 
world's  progress  have  not  limited  themselves  to  brief  working  days;  almost 
invariably  they  have  been  persistent  hard  laborers  with  whom,  impelled  by 
whatever  motive,  the  accomplishment  of  the  task  and  not  the  avoidance  of 
fatigue  has  been  the  aim.  With  the  masses  who  follow  instead  of  lead  some 
limitation  is  necessary  for  protection,  and  an  8-hour  day  is  for  the  present 
probably  the  most  just,  both  physiologically  and  sociologically.  It  seems 
reasonable  to  believe,  however,  that  when  our  knowledge  of  experimental 
methods  has  advanced  sufficiently,  by  a  careful  study  of  the  physiological 
powers  of  individuals,  on  the  one  hand,  and  the  fatiguing  capacities  of 
occupations,  on  the  other,  we  may  arrive  ultimately  at  an  adaptation  of  worker 
to  work  which  will  approach  the  physiological  ideal.  This  will  probably  re- 
quire a  work  day  of  variable  length,  variable  both  for  individuals  and  for 
occupations.  However  this  may  be,  it  is  obvious  that  society  has  not  yet 
found  a  satisfactory  solution  of  this  complex  problem. 

Piecework. — It  might  seem  that  industrial  fatigue  imposed  by  long  hours 
might  be  obviated  by  paying  workers,  not  according  to  the  time  spent,  but 
according  to  the  amount  of  work  accomplished,  and,  indeed,  the  piecework 
system  has  now  become  common  in  many  trades.  From  the  standpoint  of 
its  theory  this  system  is  to  be  commended,  for  instead  of  rewarding  all  workers 
alike,  whatever  their  grades  of  efficiency,  it  allows  those  who  are  ambitious 
and  capable  to  reap  the  benefits  of  their  greater  powers  of  accomplishment. 
But  in  practice  it  has  developed  abuses,  for  when  the  rapid  worker  becomes  in 
the  opinion  of  the  unprincipled  employer  too  rapid,  piece  wages  are  lowered 
and  further  speeding-up  is  thus  demanded.  Moreover,  the  rapid  worker  is 
often  called  upon  to  set  the  pace  for  those  who  are  physiologically  slower, 
and  thus  they  may  be  urged  on  at  a  dangerous  rate.     The  piecework  system, 


FATIGUE    AND    OCCUPATION  265 

as  thus  practised,  has  become  one  of  the  frequent  factors  in  the  production 
of  excessive  industrial  fatigue  and  has  been  widely  condemned.  Its  evils 
are  most  potent  when  it  is  combined  with  long  hours. 

Ventilation. — The  evil  effects  of  the  crowding  of  many  human  beings 
into  confined  spaces  do  not  come  from  the  chemical  vitiation  of  the  air,  for 
the  consequent  diminution  of  oxygep  and  increase  of  carbon  dioxide  are  not 
sufficient  in  amount  to  produce  evil  effects,  and  the  hypothetical  volatile 
organic  poison  of  expired  air  does  not  exist.  These  effects,  it  has  now  been 
demonstrated,?^  are  due  to  the  increase  inthe  temperature  and  the  humidity 
of  the  air,  aided  by  its  laclc  of  motion.  Increase  in  surrounding  temperature 
makes  it  more  difficult  for  the  body  to  throw  off  by  radiation  and  conduction 
the  excess  of  heat  which  it  is  constantly  producing;  increase  in  humidity  adds 
to  this  difficulty  by  diminishing  the  eooling  evaporation  of  perspiration  from 
the  surface  of  the  body;  while  if  the  air  be,  not  in  motion  the  hot  humid  en- 
velope next  the  skin  does  not  give  place  to  a  cooler  dryer  layer  with  its 
relieving  quality.  .The  result  is  an  elevation  of  bodily  temperature,  a  diminu- 
tion of  vasomotor  tone,  a  gorging  of  the  skin  with  blood  and  its  consequent 
removal  from  the  brain  and  elsewhere,  increased  perspiration,  and  the  bodily 
discomfort,  sleepiness,  headache,  and  other  characteristic  sensations  of  a 
"close"  room.  In  such  an  environment  there  are  sensations  of  fatigue  and 
less  inclination  to  do  either  physical  or  mental  work,  and  under  extreme 
conditions  actual  inability  to  acccomplish  as  much  with  the  early  oncoming 
of  exhaustion. ^^  The  following  table  gives  the  temperatures  in  degrees 
Fahrenheit  that  have  been  observed  in  various  work  places: — • 

Starching  and  ironing  in  laundries 95 

Tending  electric  furnaces 100-120 

Vulcanizing  and  japanning 90 

Evaporating  rooms  of  sugar  refineries 110-115 

Copper  reduction 100 

Manufacture  of  oxygen 100-120 

Bakeries 90 

Fatigue  and  Accidents.— Accidents  to  workmen  are  caused  by  something 
going  wrong  with  either  the  machine  or  the  man.  The  larger  number  of 
industrial  accidents  are  probably  due,  to  the  latter.  Of  2678  accidents  in 
the  state  of  Illinois  in  1910  Bogardus^^  found  17.2  per  cent,  to  result  from 
events  beyond  the  control  of  the  injured — the  breaking  of  machinery,  the 
bursting  of  boilers,  flying  pieces  of  metal — and  the  remaining  82.8  per  cent, 
to  come  from  lack  of  proper  movements  by  the  workman  himself.  It  is  now 
generally  recognized  that  fatigue  is  an  important  factor  in  the  causation  of 
industrial  accidents.  This^  is  indicated  by  the  time  of  their  occurrence. 
Bogardus  found  them  to  increase  in  number  gradually  throughout  the 
forenoon  reaching  a  maximum  between  11  and  12  o'clock,  to  diminish  sharply 
during  the  hour  when  most  workers  are  having  their  luncheon,  and  to  rise 
progressively  to  a  second  and  equally  large  maximum  between  4  and  5  o'clock 


266 


FATIGUE   AND    OCCUPATION.       NEUROSES 


(Fig.  12).  Summarizing,  conversely,  the  statistics  from  a  large  number  of 
industries,  the  Committee  of  the  British  Association^  states  the  accident 
immunity  in  the  successive  5  hours  of  a  spell  of  work  to  be  ''very  great, 
great,  fair,  small,  fair."  A  progressive  increase  through  both  forenoon  and 
afternoon  is  shown  by  the  statistics  of  most  countries  where  accurate  records 
have  been  made,  but  the  two  maxima  usually  occur  before  the  final  hour. 
This  falling-off  in  number  toward  the  end  of  each  half-day  is  usually  ascribed 
partly  to  the  decrease  in  the  number  of  persons  working,  partly  to  a  more 
leisurely  attitude  of  most  of  the  workers,  and  partly  to  a  spurt  on  the  part 
of  a  few  who  are  stimulated  to  more  acute  attention  and  greater  care  by  the 
prospective  release  from  work.  Besides  the  daily  course  of  accidents  there 
is  in  certain  industries  a  weekly  progression,  rnore  injuries  occurring  late  in 
the  week  than  early.  Monday  usually  breaks  into  the  regularity  of  the 
series  by  exhibiting  a  considerable  number,  which  has  been  ascribed  to  dissi- 


No.  of  accidents 
Hours 

7  to         8  a.  m. 

8  to         9  a.  m . 

9  to       10  a.  m. 

10  to       ii'a.  m. 

11  a.  m.  to  12  m. 

12  m.       to    I  p.  m. 
li  ito    2  p.  m. 

2  to    3  p.  m. 

3  to    4  p.  m. 

4  to    5  p.  m. 

5  to    6  p.  m. 
Other  hours 


ISO  200  250  300 


l__ 

1 

1 

1 

( 

I 

1 

L 

1 

1 

1 

Fig.  12. — The  distribution  of  industrial  accidents  during  the  working  day. 

Bogardiis.) 


{From 


pation  on  the  day  of  rest;  this  inference  is  probably  not  wholly  justified. 
The  day  after  any  holiday  is  similarly  marked. 

/'That  fatigue  is  one  of  the  pronounced  causes  of  industrial  accidents  can 
no  longer  be  doubted.  Modern  industrial  work  demands  on  the  worker's 
part  keenness  of  attention  and  precision  of  movement.  A  hair's  breadth 
often  marks  the  dividing  line  between  safety  and  harm.  Without  a  sharp 
focus  of  attention,  without  accurate  coordination  of,  the  muscles  involved  in 
an  act,  the  workman  may  come  into  contact  with  the  molten  metal,  or  touch 
the  moving  knife,  or  become  caught  in  the  revolving  gear.  Both  keenness 
of  attention  and  precision  of  movement  are  impaired  in  fatigue,  and  thus 
the  work  leads  the  worker  on  to  his  own  injury.  This  is  often  ascribed  to 
his  carelessness,  and  yet  in  many  cases  carelessness  has  a  physiological  basis 
in  fatigue,  and  thus  we  get  back  to  the  depression  of  the  physiological  powers 
as  one  of  the  physical  essentials  of  liability  to  accident.     , 


FATIGUE    AND    OCCUPATION  267 

Scientific  Management  and  Fatigue. — In  recent  years  there  has  arisen  a 
new  system  of  organizing  and  conducting  industrial  work,  known  as  scientific 
management,  and  it  has  been  enthusiastically  advocated  and  widely  adopted.^' 
It  aims  to  find  the  worker  best  fitted  for  a  particular  task  and  then  to  bring 
him  to  his  maximum  efficiency  therein.  This  is  done  through  a  careful  pre- 
liminary study  by  the  efficiency  engineer  of  the  task  itself,  its  requirements 
and  the  best  ways  of  satisfying  them,  through  the  improvement  of  the 
machines  required,  the  elimination  of  unnecessary  motions  by  the  worker, 
the  introduction  of  frequent  rest  periods,  and,  in  general,  the  arrangement 
of  all  conditions  so  as  to  secure  the  doing  of  the  task  in  question  and  no 
other,  and  its  performance  in  the  quickest  possible  time  of  which  the  worker 
without  detriment  to  his  physiological  powers  is  'capable.  By  eliminating 
useless  motions  and  concentrating  on  those  activities  that  upon  analysis  are 
found  to  be  essential  to  the  performance  of  the  task  much  unnecessary  fatigue 
can  be  avoided.  It  is  obvious,  however,  that  the  greater  exercise  of  the 
particular  neuromuscular  mechanisms  that  are  involved  leads  to  their  greater 
fatigue — we  seem, to  have  here  the  proper  conditions  for  speeding-up  with  all 
its  possibilities  of  overstrain  and  exhaustion.  Anything,  however,  that 
produces  overstrain  and  exhaustion  diminishes  the  maximum  efficiency  of 
the  worker  and  thus  (defeats  one  of  the  fundamental  conditions  of  scientific 
management,  and  hence  adequate  resting  periods,  brief  but  frequent,  must 
be  provided.  Taylor,-^  the  leader  in  the  new  system,  found  that  in  the 
handling  of  pig  iron,  each  pig  weighing  92  lbs.,  a  first-class  workman  should 
be  free  from  his  load  during  57  per  cent,  of  his  daily  working  time.  With 
lighter  loads  this  time  may  be  decreased — with  a  half  pig  to  42  per  cent,  of 
the  day.  By  scientifically  systematizing  the  work  of  handling  pig  iron  and 
selecting  and  educating  the  workmen,  Taylor  increased  the  daily  output  of 
each  man  from  12^^  to  473^^  tons,  apparently  without  overstraining  him. 
Similarly  Gantt-^  by  scientific  management  was  able  to  increase  the  production 
in  the  various  operations  of  a  bleachery  by  55  to  275  per  cent.,  in  small  au- 
tomatic screw-machine  work  by  25  to  250  per  cent.,  and  in  large  auto- 
matic machine  work  by  30  to  215  per  cent.  Gilbreth^^  reports  that  in 
building  a  brick  wall,  while  the  customary  rate  was  120  bricks  laid  by  each 
man  in  one  hour,  one  who  was  skilled  in  the  new  method,  by  which  the 
muscular  motions  required  for  each  brick  were  reduced  from  eighteen  to 
five,  was  able  to  lay  350  bricks  in  the  same  time.  In  inspecting  and 
selecting  bicycle  balls  35  .girls  under  the  new  system  were  able  to  do  the 
work  formerly  done  by  j2o.  In  all  cases  wages  are  materially  increased 
and  thus  there  is  added  a  powerful  incentive  to  the  accomplishment  of 
quick  work. 

In  theory  scientific  management  seems  to  oflfer  a  method  by  which  ex- 
cessive industrial  fatigue  may  be  avoided,  and  in  practice  at  its  best  it  doubt- 
less frequently  accomplishes  this.  Just  as,  however,  the  actualities  of 
practice  are  often  far  removed  from  the  ideals  of  theory,  so  here  the  great 


268  FATIGUE    AND    OCCUPATION.    NEUROSES 

danger  would  seem  to  lie  in  the  misuse  of  the  new  system,  in  an  increase  of 
work  done  without  adequate  regard  to  the  powers  and  the  welfare  of  the 
worker.  Whether  such  a  result  actually  occurs  and,  if  so,  how  frequently, 
we  have  at  present  no  adequate  knowledge.  There  is  little  in  the  literature 
of  the  new  system  to  indicate  that  its  enthusiastic  apostles  understand  the 
nature  of  fatigue  and  its  manifestations.  Its  writers,  indeed,  say  little  of 
this  phase  of  their  subject.  It  is  obvious  that  there  is  much  needed  the 
collection  of  data  from  the  new  experience  and  the  comparison  of  them  with 
the  facts  of  traditional  industrialism.  Only  thus  can  we  learn  whether 
scientific  management  offers  to  the  worker  real  release  from  the  unwarranted 
strain  of  his  occupation. 

REFERENCES 

1  The  most  comprehensive  study  of  fatigue  in  its  industrial  aspects  is:  Goldmark, 
Josephine — Fatigue  and  Efficiency,  New  York,  1912.  See  also,  in  the  Proceedings 
of  the  British  Association  for  the  Advancement  of  Science,  1915,  the  report  of 
the  Committee  to  Study  the  Question  of  Fatigue  from  the  Economic  Standpoint. 

-  For  accounts  of  the  general  physiology  of  fatigue  the  reader  may  consult:  Lee,  Frederic 
S. — Fatigue.  Journal  of  the  American  Medical  Association,  1906,  XLVII,  page  1491 5 
also  Harvey  Lectures,  1905-06,  Philadelphia,  1906.  The  Nature  of  Fatigue. 
Popular  Science  Monthly,  1910,  LXXVI,  page  182.  The  Action  of  Normal  Fatigue 
Substances  on  Muscle.  American  Journal  of  Physiology,  1007,  XX,  page  170. 
The  Cause  of  the  Treppe.  Idem,  1907,  XVIII,  page  267.  Pseudo-fatigue  of 
the  Spinal   Cord.     (With  S.  Everingham).  Idem,  1909,  XXIV,  page  384. 

^  Weichardt,  Wolfgang — Uber  Ermiidungsstoffe,  Stuttgart,  1912. 

^  Ayre's,  Leonard  P. — Bicycling  World  and  Motorcycle  Review,  April,  191 1,  page  78. 

^  Gruber,  C.  M. — American  Journal  of  Physiology,  1913,  XXXII,  page  437.  See  also  Can- 
non, W.  B. — Bodily  Changes  in  Pain,  Hunger,  Fear  and  Rage,  New  York,  1915. 

^  Mosso,  A.- — Fatigue,  New  York,  1904. 

^  Offner,  Max— Mental  Fatigue,  Baltimore,  191 1.  Whipple,  Guy  M.— Manual  of  Mental 
and  Physical  Tests,  Baltimore,  1910. 

*  Abbott,  A.  C.^ — University  of  Pennsylvania  Medical  Bulletin,  1910,  XXIII,  page  169. 

8  Fisher,  Irving — Report  on  National  Vitality,  Washington,  Government  Printing 
Office,  1909. 

1°  Lee,  Frederic  S. — The  Causes  of  Fatigue  in  Certain  Pathological  States.  British  Medical 
Journal,  1906,  II,  page  1806. 

11  Pieraccini,  G. — Atti  del  I  Congresso  Internazionale  per  le  Malattie  del  Lavoro,  Milan, 

1906,  page  113. 

12  Roth,  E. — Bericht  iiber  den  XIV   internationalen  Kongress   fiir  Hygiene  und  Demo- 

graphic, Berlin,  1907,  II,  page  593. 

1'  Leubuscher,  P.,  and  Bibrowicz,  W.^ — Deutsche  medizinische  Wochenschrift,  1905,  XXXI, 
page  821. 

"  Schonhals,  Paul — tjber  die  Ursachen  der  Neurasthenic  und  Hysteric  bei  Arbeitern, 
Berlin,  1906. 

1^  Treves,  Z. — Bericht  iiber  den  XIV  internationalen  Kongress  fiir  Hygiene  und  Demo- 
graphic, Berlin,  1907,  II,  page  626. 

18  Butler,  Elizabeth  B.— Women  and  the  Trades:  The  Pittsburgh  Survey,  New  York, 
1911. 

1^  Bulletin  of  the  United  States  Bureau  of  Labor,  93,  Washington,  1911.  (Summary  of 
British  Board  of  Trade  Report.) 


FATIGUE    AND    OCCUPATION  269 

"  Thirteenth  Census  of  the  United  States,  x,  Manufactures,  1909,  Washington,  1913. 

1'  Report  on  Conditions  of  Employment  in  the  Iron  and  Steel  Industry  in  the  United 
States,  Washington,  1911.  See  also  Fitch,  John  A. — The  Steel  Workers:  The 
Pittsburgh  Survey,     New  York,  1910. 

-"  Abbe,  Ernst — Gesammelte  Abhandlungen,  Bd.  Ill,  Jena,  1906. 

-'  Lee,  Frederic  S. — Fresh  Air.  Popular  Science  Monthly,  1914,  LXXXIV,  page  313. 
Laboratory  Experiments  with  Air.  Journal  of  the  American  Medical  Association, 
1914,  LXIII,  page  1625.  The  Effects  of  Temperature  and  Humidity  on  Fatigue. 
American  Journal  of  Public  Health,  191 2,  II,  page  863.  Lee,  Edwards  and  Others. 
— The  Action  of  Certain  Atmospheric  Conditions  on  Body  Temperature  and  the 
Vascular  System.  Proceedings  of  the  Society  for  Experimental  Biology  and  Medi- 
cine, 1915,  XII,  page  72.  See  also  other  publications  of  the  New  York  State 
Commission  on  Ventilation. 

*-  Bogardus,  Emory  S. — The  Relation  of  Fatigue  to  Industrial  Accidents.  American 
Journal  of  Sociology,  191 2,  XVII. 

-'Thompson,  C.  B. — Scientific  Management,  Cambridge,  1914. 

^*  Taylor,  F.  W. — Principles  of  Scientific  Management,  New  York,  1911. 

-5  Gantt,  H.  L. — Work,  Wages  and  Profits,  New  York,  1913. 

-^  Gilbreth,  Frank  B. — Bricklaying  System,  Chicago,  1909.  ^lotion  Study,  New  York, 
1911. 

-'  Kent,  A.  F.  Stanley^ — British  Home  Office.  Interim  Report  on  an  Investigation  of 
Industrial  Fatigue  by  Physiological  Methods,  London,  1915. 

^*  Winslow,  Kimball,  Lee,  Miller,  Phelps,  Thorndike,  and  Palmer — Some  Results  of  the 
First  Year's  Work  of  the  New  York  State  Commission  on  Ventilation.  American 
Journal  of  Public  Health,  191 5,  V,  page  85.  Lee,  Frederic  S.,  and  Scott,  Ernest 
L. — The  Action  of  Temperature  and  Humidity  on  the  Working  Power  of  Muscles 
and  on  the  Sugar  of  the  Blood.     American  Journal  of  Physiology,  1916,  XL. 


CHAPTER  II 
OCCUPATION  NEUROSES 

BY  E.  E.  SOUTHARD,  M.   D.,  AND  H.  C.  SOLOMON,  M.  D.,  Boston,  Mass. 

Synonyms. — Copodyskinesia;  dyskinesia;  craft  neurosis;  occupational 
dyskinesia;  Dyskinesia  fonctionelle  (functional  dyskinesia);  professional 
ataxia;  (coordinatorische)  Beschaftigungsneurosen;  affection  nerveuse 
professionnelle;  functional  spasm;  crampe  Fonctionelle;  crampe  professionelle 
fonctionelle;  fatigue  disease;  anapeiratic  paralysis;  local  chorea;  partial 
vertigo. 

The  typical  occupation  neurosis  is  writers'  cramp,  for  which  the  variety 
of  names  is  significant;  e.g.,  scriveners'  palsy,  crampe  des  ecrivains,  Schreib- 
krampf,  steel  pen  palsy,  mogigraphia,  emotional  dysgraphia,  graphospasm, 
paralysis  notariorum,  stammering  on  paper,  impotence  fonctionelle  des 
ecrivains,  loss  of  grip. 

Fundamental  and  Systematic  Studies 

The  disease  was  apparently  first  described  in  modern  times  by  Sir  Charles 
Bell,  in  1830,  and  by  a  German  author,  Briick,  in  1831.  Considerable 
discussion  followed  in  Germany  and  France,  and  was  described  in  Canstatt's 
text-book  of  medicine.  The  first  to  describe  the  disease  upon  modern  lines 
was  Duchenne,  who  developed  the  theory  of  disturbed  coordination  (see 
below).  Benedikt  in  1874  added  important  aspects  of  a  theoretical  nature 
(cell  group  coordinations  in  the  central  nervous  system).  The  first  edition 
of  Allbutt's  System  of  Medicine  contained  a  modern  account  by  G.  Vivian 
Poore.  Poore's  account  has  been  revised  and  modified  by  Head  in  the 
current  edition  of  Allbutt's  text-book,  to  which  the  reader  may  be  referred. 

General  Definition. — Oppenheim's  definition  is  the  one  most  generally 
quoted,  running  as  follows: 

By  an  occupation  neurosis  is  understood  a  disturbance  of  innervation  of 
the  muscles,  occurring  only  in  certain  complicated  movements  acquired  by 
practice,  of  such  a  nature  as  to  permit  the  same  muscles  to  respond  to  the 
will  in  all  other  actions;  thus,  in  the  typical  occupation  neurosis,  writers' 
cramp;  the  muscles  paralyzed  for  the  purpose  of  writing  are  found  to  be 
entirely  mobile  for  the  other  purposes. 

Occupation  neuroses  are  neuroses  incident  to  special  occupations,  and 
might  better  be  termed  vocational  neuroses.  They  have  been  termed  craft- 
neuroses  (Head);  but  this  term,  perfectly  suitable  for  writers'  cramp,  would 

270 


OCCUPATION    NEUROSES  27 1 

not  SO  well  fit  a  neurosis  of  preachers,  namely,  mogiphonia.  Occupation- 
neuroses  are  neuroses  of  technique  involving  muscular  action,  and  are  well- 
nigh  as  numerous  as  are  technical  vocations  themselves.  It  might  be 
inquired  whether  certain  apathies  or  neurasthenic  phenomena  could  be  re- 
garded as  a  generalized  occupation  neuroses  ("run  down  from  overwork"); 
but  this  would  be  a  doubtful  usage  of  the  term,  since  in  such  generalized  disease 
the  nervous  system  cannot  be  used  effectively  for  the  organism's  general  needs. 
The  point  of  an  occupation  neurosis,  on  the  other  hand,  lies  in  the  fact 
that  certain  muscles,  utilizable  for  all  sorts  of  other  purposes,  can  no  longer 
be  used  for  some  special  technical  purpose  in  one  particular  manner  learned 
by  practice.  Occupation  neuroses  are  diseases  of  acquired  function  and 
as  a  rule  of  somewhat  highly  specialized  function.  Seldom  do  patients 
exhibit  at  one  time  two  kinds  of  occupation  neurosis;  but  a  victim  of  writers' 
cramp  may  fall  victim  to  typewriters'  cramp  and  retain  both. 

It  is  a  question  what  "neurosis"  means  in  the  term  occupation  neurosis. 
Occupation  neuroses  are,  or  should  be,  essentially  functional  neuropathies, 
in  the  most  general  sense  of  the  term  neuropathy,  i.e.,  either  peripheral 
or  central  in  origin.  Theory  tends  to  consider  occupation  neuroses  as  neuro- 
pathies of  central  rather  than  peripheral  origin  (Benedikt).  But  practice 
tends  to  find  peripheral  origins  for  many  (G.  Vivian  Poore).  Of  course,  if 
research  should  prove  a  peripheral  (or  central)  structural  basis  for  the 
clinical  phenomena,  then  the  name  occupation  neurosis  would  be  itself 
a  misnomer. 

It  is  decidedly  of  more  than  academic  interest  to  consider  this  question 
in  individual  cases.     Consider  in  succession  certain 

Theories  of  Origin 

I.  Suppose,  with  a  few  authors,  we  consider  occupation  neuroses  to  be 
in  part  at  least  based  on  constitutional  factors  or  diatheses;  for  example : 

Fere,  1887-1900;  Bonnier,  1898;  Lanel,  1909;  Head,  1910;  Frankl- 
Hochwart,  1913. 

Modern  work  has  of  course  shown  in  all  sorts  of  mental  and  nervous 
conditions,  both  functional,  quasi  functional,  and  frankly  organic,  that 
diathetic  constitutional  factors  are  fundamental  and  indispensable  factors 
although  they  may  not  be  the  essential  ones.  The  above-mentioned  authors, 
in  practically  all  cases,  emphasize  other  non-constitutional  factors  in  addi- 
tion to  the  diatheses.  TfaS^writers  have  histories  available  in  a  number  of 
instances  to  show  strong  traces  of  hereditary  factors,  a  finding  which  is  not 
uncommon  in  the  literature.  This  constitutional  background  naturally  has 
important  bearing  upon  the  prognosis  as  well  as  upon  general  therapeutic 
measures. 

Not  only  may  the  occupation  neuroses  be  in  a  sense  diseases  of  diathesis, 
but  certain  well-recognized  diatheses  may  bring  about  phenomena  which  can 


272  FATIGUE    AND    OCCUPATION.    NEUROSES 

with  difficulty  be  distinguished  from  occupation  neuroses;  e.g.,  tremor  of 
old  age,  arteriosclerosis,  tabes  dorsalis,  and  dementia  precox,  yielding 
graphic  disorder  attributed  by  the  patient  and  his  friends  to  a  functional  effect 
of  occupation.  Parkinson's  disease  may  occasionally  suggest  occupation 
neurosis.  There  are  scattering  references  to  occupation  neurosis  in  gouty  or 
rheumatic  conditions. 

2.  We  may  also  consider  occupation  neuroses  to  be  in  some  way  depend- 
ent upon  (as  it  were,  permitted  by),  a  general  neurasthenic  condition  which 
might  be  focalized  in  a  particular  muscular  difficulty.  The  following  authors 
touch  upon  this:  Berger,  1885;  Fere,  1887-1900;  Bernhardt,  1896;  Bins- 
wanger,  1896;  Cassirer,  1900;  Mettler,  1904;  Lepinay,  1909;  Starr,  1909; 
Vogt,  1909-1910;  Head,  1910;  Bing,  191 2;  Strlimpell,  191 2;  Frankl- 
Hochwart,  1913;  Jacobson,  1913;  Oppenheim,  1913;  Jelliffe,  1914. 

The  true  neurasthenic  should,  as  a  rule,  exhibit  phenomena  of  more  general 
distribution,  involving  numerous  functions  revolving  about  his  complaints. 
The  typical  victim  of  writers'  cramp  will  exhibit  a  complete,  and  indeed  over- 
eager,  desire  to  write,  although  his  paralysis  forbids  the  process;  whereas  the 
graphic  impotence  of  the  neurasthenic  is  coupled  with  a  diminution  of  will 
or  absolute  aboulia. 

3.  The  last  few  years  have  brought  out  a  crop  of  theories  according  to 
which  occupation  neuroses  are  in  some  sense  hysterical  phenomena,  perhaps 
based  upon  inhibitions  in  a  Freudian  sense.  According  to  this  account,  a 
particular  function,  such  as  writing  or  managing  a  telegraph  key,  becomes 
impossible  because  a  derived  movement  of  an  opposite  nature  with  cramp, 
tremor,  or  ataxia  has  preempted  the  muscles  so  that  they  cannot  perform 
the  desired  act.  T.  A.  Williams,  191 2,  has  expressed  a  hypothesis  of  this 
nature,  but  according  to  him  the  psychogenesis  in  these  cases  is  not  espe- 
cially along  sex  lines.  Other  representatives  of  a  psychogenetic  basis,  at 
least  in  part,  are  Berger,  1885;  Cohn,  1897;  Leri,  1900;  Destarac,  1901; 
Brissaud,  Hallion  and  Meige,  1903;  Mettler,  1904;  Meige,  1908;  Lepinay, 
1909;  Vogt,  1909-1910;  Head,  1910;  Lewandowski,  1912;  Mohr,  1912; 
Frankl-Hochwart,  1913;  Strlimpell,  191 2;  Thomas,  J.  J.,  1913. 

By  no  means  all  of  these  authors  would  class  themselves  among  the 
Freudians,  but  they  all  to  some  extent  lay  stress  upon  functional  bases  for 
these  conditions,  conceiving  that  they  may  represent  a  form  of  psychoneu- 
rosis,  if  not  always  clearly  neurasthenic. 

4.  A  number  of  French  authors  prefer  to  class  the  occupation  neuroses 
among  the  tics;  for  example,  Leri,  1900;  Destarac,  1901;  Rudler,  1903; 
Bonnus,  1905;  Meige,  1908. 

J.  J.  Thomas  also  speaks  of  certain  training  exercises  in  writers'  cramp  as 
along  the  lines  of  treatment  in  tic. 

5.  Emphasis  upon  overexertion  in  the  particular  professional  act 
has  been  laid  by  Althaus,  1870;  Vance,  1873;  Berger,  1885;  Benedikt,  1897; 
Church,  1898;  Mettler,  1904;  Meige,  1908;  Vogt,  1909-1910;  Head,  1910; 


OCCUPATION   NEUROSES  273 

Bing,  191 2;  Frankl-Hochwart,  1913;  Jelliflfe,  191 2;  Thomas,  1913;  Cursh- 
man,  1915. 

Most  of  these  authors  combine  the  fact,  or  hypothesis,  of  overexertion 
with  a  variety  of  other  explanatory  schemes  for  the  production  of  the  neurosis; 
thus,  overexertion  may  conceivably  be  muscular  or  neural  and  if  neural, 
it  might  be  peripheral  or  central  in  origin.  But  many  of  the  above-named 
authors  consider  that  the  local  use  of  the  muscles  in  question  has  set  up  a 
myositis,  bursitis,  tenosynovitis,  or  other  local  change  of  a  chronic  inflam- 
matory nature  which  could  interfere  with  fine  movements  and  still  permit 
coarser  movements  to  be  produced.  Such  changes,  which  are  doubtless  not 
seldom  found  in  cases  that  receive  the  diagnosis  occupation  neurosis,  might 
well  produce  pain  when  muscles  are  used,  particularly  for  finer  coordinate 
movements. 

Under  this  heading  should  be  mentioned  also  the  toxins  of  fatigue  which 
Weichardt  has  described;  and  the  work  of  Lee  upon  the  production  of  certain 
substances  in  prolonged  activity  of  muscles,  such  as  carbon  dioxide,  para- 
lactic  acid,  and  ammonopotassium-phosphate,  is  perhaps  in  point.  It  is 
not  impossible  that  future  research  may  work  out  hypotheses  along  the  lines 
of  the  hormones.  Of  course  it  is  not  necessary  that  the  substances  produced 
by  muscular  action  or  overexertion  shall  exert  their  effects  upon  the  muscles 
in  question,  but  they  may  act  through  the  circulation  or  by  way  of  tissue  clefts 
upon  the  nervous  system,  notably  upon  the  unstable  surfaces  of  separation 
or  synapses  between  the  conducting  nerve  elements  (Lee). 

6.  There  has  been  a  recrudescence  of  arterial  spasm  theories  which,  al- 
though given  up  largely  for  the  explanation  (after  the  fashion  of  Theodor 
Meynert)  of  melancholia  and  mania,  are  thought  possibly  applicable  to  the 
occupation-neurosis  group.  As  leaning  in  part  to  such  a  doctrine  may  be 
mentioned:  Goldflam,  1901;  Massaut,  1901;  Goldstein,  1901;  Determann, 
1905;  Erb,  1906;  Raymond,  1906;  Kronenberg,  1908;  Lanel,  1909;  Lepinay, 
1909;  Head,  1910. 

Nothnagel  had  already  reported,  in  1867,  a  case  which  he  interpreted  in 
this  way.  According  to  this  account,  the  spasmodic  form  of  writers'  cramp 
would  in  some  degree  resemble  the  phenomenon  of  intermittent  claudication. 
The  spasm  in  question  is  conceived  to  be  a  local  one.  No  extended  applica- 
tion of  the  idea  of  arterial  spasm  as  occurring  in  the  central  nervous  system 
as  a  basis  for  peripheral  effects  has  been  found  in  the  literature. 

7.  Myotonia. — Curschmann,  1905,  has  laid  emphasis  upon  the  close 
resemblance  of  cases  of  writers'  cramp  to  myotonia.  He  has  reported  the 
case  of  a  young  brush  maker  whose  partial  myotonia  closely  simulated  a 
professional  neurosis  with  muscular  weakness,  paraesthesia,  and  spasm. 

8.  Under  the  influence  of  Duchenne  and  Benedikt,  the  majority  of  sys- 
tematic writers,  and  a  great  many  of  the  monograph  and  periodical  writers, 
have  supported  what  may  be  called  the  central  nervous  theory  of  origin.  It 
may  almost  be  said  that  such  a  definition  as  that  given  above  from  Oppen- 

18 


2  74  FATIGUE    AND    OCCUPATION.       NEUROSES 

heim  really  involves  such  a  central  nervous  origin,  although  it  is  far  from 
agreed  as  to  the  exact  nature  of  the  central  dysfunction  which  gives  rise  to 
the  dyskinesia.  Among  the  supporters  in  part  or  as  a  whole  of  this  account 
may  be  mentioned  Giegel,  1864;  Solly,  1864;  Althaus,  1870;  Benedikt,  1874, 
1897;  Beard,  1879;  Seeligmiiller,  1882;  Berger,  1885;  Bernhardt,  1896;  Cohn. 
1897;  Church,  1898;  Cassirer,  1900;  Savill,  1901;  Haskovec,  1902,  1906; 
Brissaud,  Hallian  and  Meige,  1903;  Mettler,  1904;  Edinger,  1906;  Gowers, 
1907;  Lepinay,  1909;  Vogt,  1909,  1910;  Head,  1910;  Frankl-Hochwart,  1913; 
Binswanger,  1896;  Duchenne,  i860;  Kouindjy,  1904-5;  Striimpell,  1912; 
Thomas,  1913. 

Duchenne,  in  i860,  in  his  work  "L'electrisation  localisee,"  said  that  he 
defined  as  spasm  with  functional  impotence  of  muscles  certain  affections  char- 
acterized either  by  continuous  contractions  or  by  clonic  contractions.  The 
contractions  might  be  painful,  or  they  might  not  be  accompanied  by  pain. 
The  clonic  contractions  might  appear  in  the  form  of  tremors.  The  muscular 
impotence  might  manifest  itself  neither  by  contractions  nor  by  pain,  but 
solely  in  the  exercise  of  certain  voluntary  or  instinctive  movements  localized 
in  the  muscles  appropriate  to  (synergic  with)  the  movement. 

Duchenne  strongly  leaned  to  the  central  view.  He  quoted  a  patient 
who  suffered  from  right-sided  writers'  cramp  and  learned  to  write  with  his 
left  hand,  only  to  become  victim  to  left-sided  cramp.  Duchenne  felt  that 
such  cases  would  argue  an  extension  of  the  morbid  state  from  one  side  of 
the  spinal  cord  to  the  other. 

Other  authors,  notably  Benedikt,  take  into  account  not  the  spinal  cord 
alone,  but  the  higher  levels  and  notably  the  voluntary  levels  of  the  nervous 
system.  Benedikt,  1874,  was  far  more  concrete  than  Duchenne  in  his 
hypotheses.  He  insisted  that  the  cells  disordered  in  writers'  cramp  must 
be  associative  cells  rather  than  the  cells  governing  single  movements,  for  if 
the  latter  were  affected,  then  paralysis  must  follow  in  such  wise  that  none 
of  the  muscles  in  question  could  act.  Benedikt  assumed  a  condition  of  either 
(o)  heightened  irritability  or  {b)  lessened  irritability  in  a  group  of  cells 
superintending  the  coordination  of  certain  movements.  In  the  case  of 
heightened  cell  irritability,  the  normal  stimulus  from  other  areas  (that  is, 
by  the  "will")  produces  a  cramp  of  the  muscles.  In  case  there  is  a  lessened 
cell  irritability,  there  will  be  a  paralysis  of  coordination  and  the  pen  will 
drop  loosely  from  the  hand. 

9.  The  modern  work  has  conspired  to  produce  a  group  of  peripheral 
theories  of  the  origin  of  occupation  neuroses,  but  it  is  a  question  whether, 
if  proof  could  be  adduced  for  such  theories,  the  entity  or  group  of  entities 
called  occupation  neuroses  would  not  largely  fall  to  the  ground.  That  this 
would  be  the  case  is  shown  by  the  great  emphasis  now  being  laid,  even  in 
systematic  accounts  {e.g.,  Head  following  the  lead  of  G.  Vivian  Poore),  upon 
actual  or  conceived  local  changes  in  muscles,  nerves,  their  investments,  or 
adjacent  structures.     Time  and  again  in  the  course  of  preparing  this  syste- 


OCCUPATION    NEUROSES  275 

matic  account  we  have  been  impressed  with  the  notion  that  no  such  group 
of  diseases  actually  exists,  but  that  every  concrete  case  deserving  the  appella- 
tion will  turn  into  something  far  more  definite  than  such  a  definition  as  that 
of  Oppenheim's  above  would  entail.  Vivian  Poore  gave  a  number  of  reasons 
against  regarding  central  disturbance  of  coordination  as  the  basis  of  these 
so-called  neuroses.  Poore  stated  that  he  had  never  seen  a  case  without 
evidence  of  peripheral  change.  In  most  of  his  cases,  he  had  no  evidence 
of  disease  except  at  the  periphery.  The  disease  at  the  periphery  consisted 
of  muscular  paresis,  muscular  spasm,  localized  tremor,  fibrillary  tremors  of 
certain  muscles,  alteration  of  muscular  irritability,  localized  pain,  nerve 
tenderness.  Poore  writes:  "One  or  more  of  these  symptoms  was  always 
present.  The  writers'  cramp  of  the  text-books,-in  which  failure  of  the  writing 
power  is  the  sole  symptom,  I  have  never  seen."  In  most  cases  the  symp- 
toms grew  more  or  less  gradually,  and  accordingly  did  not  seem  to  be  related 
to  a  sudden  debacle  of  coordination.  Accordingly  Poore  thinks  that 
writers'  cramp  belongs  in  a  catalogue  of  diseases  near  neuralgia. 

An  American  neurologist.  Beard,  also  thought,  in  1879,  that  the  disease 
was  a  peripheral  and  local  disease  of  nerves  and  muscles.  He  thought  it 
became  only  secondarily,  and  rarely,  a  central  general  disease.  Another 
American  neurologist,  W.  E.  Paul,  also  follows  the  tendency  of  Poore  and 
Beard.  Paul  states  that  the  "principal  result  of  an  analysis  of  these  200 
(Massachusetts  General  Hospital)  cases  is  that  muscles,  joints,  and  regions 
near  joints  are  preponderantly  the  loci  of  sensory  symptoms  rather  than 
the  course  and  distribution  of  definite  peripheral  nerves."  He  goes  on  to 
say  that  "This,  then,  is  my  conception,  that  the  impacts,  compressions, 
squeezings,  tensions,  and  stresses  of  excessive  physiological  functioning, 
acting  on  muscle  tissue,  or  on  sensory  and  motor  nerve  structures  which  run 
in  the  soft  tissues  and  terminate  in  muscle,  tendon,  joints,  or  fasciae,  bring 
about  neurolytic  or  myolytic  changes  responsible  for  the  occupation  neuroses 
and  so-called  occupation  neuritis  and  occupation  pain." 

We  have  gone  over  a  number  of  cases  in  local  Boston  clinics,  and  Paul's 
results  at  the  Massachusetts  General  Hospital  have  been  confirmed.  No  case 
has  been  found  which  entirely  satisfies  the  general  definition  of  Oppenheim. 
In  the  first  2000  cases  in  the  Harvard  Medical  School  Out-patient  Clinic,  and 
its  continuation  in  the  Out-door  Department  of  the  Peter  Bent  Brigham  Hos- 
pital, the  diagnosis  of  occupation  neurosis  has  not  occurred. 

We  feel  that  modern  finer  methods  in  local  neurological  diagnosis  may 
serve  to  destro}^  the  functional  nature  of  other  doubtful  cases.  In  a  case 
which  might  well  be  regarded  as  one  of  occupation  neurosis,  lately  seen,  a 
case  which  might  be  termed  one  of  stonecutters'  palsy,  we  were  able  to  show 
long  after  the  patient  had  ceased  to  complain  of  subjective  sensory  disor- 
der a  definite  anaesthesia  to  faradism  (Martin  sensory  tests). 


276 


FATIGUE   AND    OCCUPATION.    NEUROSES 


Varieties  of  Occupation  Neuroses 

A  book  of  inordinate  length  would  be  required  to  deal  with  all  varieties. 
Indeed,  Vogt  remarks  that  there  is  an  endless  number  of  occupation  neuroses, 
as  many  as  there  are  possibilities  in  handicraft  activities  and  in  varieties  of 
technique.  New  types  of  occupation  neuroses  are  developed  as  new  handi- 
crafts and  techniques  develop.  The  following  is  a  partial  list  of  occupation 
neuroses  aside  from  the  typical  neurosis  of  all — namely,  writers'  cramp. 
These  have  been  obtained  from  the  literature,  others  could  be  added  almost 
ad  libitum. 


Auctioneer 

Bicyclist 

'Cellist 

Cigar  roller 

Cornetist 

Clarionetist 

Compositor 

Diamond  cutter 

Dancer 

Engraver 

Enameller 

Flutist 

Flower  maker 

Gold  worker 

Harpist 

Hammerman 

Knitter 

Locksmith 


Lithographer 

Lathe  turner 

Laborer 

Letter  sorter 

Milker 

Miners'  nystagmus 

Mason 

Money  counter 

Microscopist 

Nail  maker 

Organist 

Pianist 

Painter 

Preacher 

Shoemaker 

Smith 

Sawyer 

Scissors  sharpener 


Sewing  machinist 

Singer 

Seamstress 

Sailor 

Shaver 

Trap  drummer 

Tennis  player 

Tailor 

Tinker 

Telegrapher 

Trumpeter 

Turner 

Treadler 

Tawer 

Watchmaker 

Walker 

Zitherist 


It  is  worth  while  to  describe  writers'  cramp  more  in  detail  than  the  other 
occupation  neuroses  because  it  is  more  frequent  than  any  other  and  because 
it  has  been  more  frequently  described.  Writers'  cramp  is  still  the  most  fre- 
quent form  of  occupation  neurosis,  although  the  number  of  cases  has  appre- 
ciably diminished  since  the  advent  of  typewriters,  which  has  of  course  en- 
tailed (but  apparently  in  smaller  numbers)  a  new  form  of  occupation  neurosis. 
Perhaps  the  best  description  of  writers'  cramp  may  be  obtained  from  Gowers' 
text-book,  although  the  disease  is  fully  described  in  various  places. 

Writers'  cramp  is  commonly  stated  to  occur  in  twice  as  many  males  as 
females.  It  occurs  in  all  adult  ages,  and  Gowers  found  two  cases  between 
10  and  20,  52  between  20  and  30,  50  between  30  and  40,  32  between  40  and  50, 
12  between  50  and  60,  and  5  in  patients  over  60.  This  series  of  153  cases 
included  33  by  Poore,  64  by  Berger,  and  54  of  Gowers'  own  cases.  There 
seems  to  be  no  special  racial  tendency  to  writers'  cramp. 

An  hereditary  tendency  to  nervous  affections  of  various  sorts  has  been 
found  by  certain  authors.  We  have  ourselves  come  upon  an  interesting 
example  of  familial  writers'  cramp.  This  case,  a  woman  of  44,  was  a  copyist, 
with  a  younger  brother  who  has  already  at  this  time  (aged  37)  developed  diffi- 


OCCUPATION   NEUROSES  277 

culty  in  his  writing.  The  father  of  these  two  was  likewise  a  copyist,  and  died 
at  the  age  of  75  with  mental  symptoms  and  brain  disease.  The  father's 
brother  and  sister  also  died  in  the  seventies  of  shock,  but  neither  they  nor 
their  children  showed  any  trace  of  writers'  palsy,  although  some  of  the  chil- 
dren have  been  engaged  in  clerical  work. 

Among  the  general  underlying  conditions  which  favor  the  development  of 
writer's  cramp  have  been  mentioned  neurasthenia,  a  variety  of  diatheses  and 
general  conditions  (gout,  rheumatism,  Bright's  disease,  syphilis,  arterio- 
sclerosis), overexertion,  trauma,  alcoholism,  overuse  of  tobacco,  etc.  Empha- 
sis has  often  been  laid  upon  emotion,  especially  the  emotion  of  anxiety,  as  a 
contributory  cause.  The  Freudians  are  not  loath  to  offer  a  sexual  basis  for 
certain  cases.  Some  authors  speak  of  influences  lowering  the  tone  of  the 
nervous  system,  hypo-oxidation  and  the  like;  or  the  use  of  poor  pens;  or  the 
continual  improper  holding  of  the  pen;  or  even  the  use  of  poor  paper.  Some- 
what more  to  the  point  probably  are  suggestions  to  the  effect  that  painful 
affections  of  the  fingers,  neuritis,  and  neuralgia  lie  at  the  basis  of  certain 
cases.  Much  has  been  written  concerning  the  art  of  penmanship  with  rela- 
tion to  the  use  of  the  larger  muscles,  and  an  excursion  from  the  elbow  and 
shoulder  rather  than  from  the  wrist  alone.  It  is  thought  that  the  employ- 
ment of  these  wider  excursions  diminishes  fatigue,  on  the  basis  that  the 
smaller  the  muscles  the  greater  the  fatigue. 

The  typical  case  of  writers'  cramp,  accordingly,  is  likely  to  appear  in  the 
male,  but  the  figures  signify  rather  that  under  European  conditions  more 
men  than  women  follow  clerical  work  for  a  living.  Heredity  will  be  found 
as  a  rule  to  be  so  vague  as  not  to  aid  in  the  diagnosis.  It  is  probable  that 
the  various  "underlying  conditions"  above  mentioned  give  rise  to,  or  per- 
mit, the  occurrence  of  neuritis  rather  than  the  true  neurosis  which  classical 
authors  signify  by  the  term  "writers'  cramp." 

I.  True  writers'  cramp  in  the  narrow  sense  of  the  term  (neurosis  minus 
local,  peripheral,  structural,  or  functional  changes):  Poore  found  32  cases 
in  a  personal  series  of  75  which  he  was  inclined  to  put  in  the  group  of  true 
writers'  cramp,  but  he  states  that,  "In  every  case  of  impaired  writing 
power  that  I  have  seen,  there  has  been  evidence,  more  or  less  marked,  of 
derangement  of  one  or  more  of  the  muscles  used  for  writing."  Poore 's  method 
of  determining  peripheral  alteration  in  these  cases  was  by  artificially  stimu- 
lating the  muscles  used  in  writing  by  means  of  faradism.  He  maintains 
that  he  found  an  excess  of  irritability  in  one  or  more  of  the  writing  muscles 
in  most  cases.  Benedikt,  in  1874,  remarked  that  there  was  an  increased 
faradic  irritability  in  the  earlier  phases  of  the  disease,  whereas  later  phases 
were  attended  by  a  decrease.  Benedikt,  in  1897,  remarks  that  the  actually 
paralyzed  muscles  exhibit  a  decreased  electrical  reaction,  whereas  the 
neighboring  muscles  exhibit  an  increased  irritability.  It  may  be  remarked 
in  passing  that,  if  these  remarks  of  Benedikt  are  correct,  then  the  innervation 
streaming  down  from  the  central  nervous  system  with  a  perfectly  normal 


278  FATIGUE    AND    OCCUPATION.       NEUROSES 

intensity,  rate,  and  periodicity  might  on  account  of  local  neuropathic  or 
myopathic  conditions  produce  the  effect  of  ataxic  writing,  or  even  agraphia, 
without  our  being  forced  to  the  hypothesis  of  central  changes.  Other 
authors  are  not  so  emphatic  in  their  statements  concerning  altered  local 
irritability,  although  most  concede  a  slight  degree  of  quantitative  change 
to  the  ordinary  electrical  tests. 

The  sub-groups  of  so-called  true  writers'  cramp  are,  according  to  Gowers 
and  most  systematic  authors,  the  following: 

(a)  Spastic. 

(b)  Paralytic. 

(c)  Tremulous. 

(d)  Neuralgic. 

(a)  Spastic  Writers'  Cramp. — The  onset  in  the  spastic  form  is  gradual, 
as  a  rule,  beginning  with  slight  errors  in  penmanship,  such  as  irregular 
strokes  and  marks  due  to  unintended  movements;  the  writer  finds  his  pen 
being  held  overtightly;  the  total  process  of  writing  becomes  slower;  the 
tight  holding  of  the  pen  augments  to  a  genuine  spasm,  and  the  spastic 
condition,  at  first  confined  to  a  few  muscles,  spreads  to  more  numerous 
muscles.  In  those  few  cases  in  which  the  spastic  form  of  writers'  cramp 
begins  abruptly,  Gowers  states  that  the  attack  is  ushered  in  by  local  pain. 

The  fully  established  writers'  cramp  in  spastic  form  shows  almost  always 
tonic  spasm  interrupted  at  rare  intervals  by  a  slight  accentuation  of  the 
muscular  contractions  in  the  form  of  a  starting  or  jerking  movement.  The 
tonic  spastic  cases  are  often  accompanied  by  local  tremors. 

There  are  more  rarely  clonic  types  of  the  spastic  form.  The  clonus 
may  be  so  severe  also  as  to  throw  the  pen  across  the  room. 

The  startling  feature  of  such  a  tonic  or  clonic  situation  in  the  wTiting  arm 
of  the  patient  is  that  the  patient  can  at  the  same  time  perform  quite  properly 
and  readily  practically  all  other  coordinative  movements  as  well  as  simple 
movements  which  are  innervated  through  the  same  peripheral  nerves.  The 
altered  potentiality  of  movement  is  so  sharply  defined  that  certain  subjects 
becoming  unable  to  use  a  pen  can  still  write  with  a  pencil.  It  is  historically 
curious  that  with  the  modern  increase  of  writing  and  the  introduction  of  the 
steel  pen,  it  was  common  to  hear  it  said  that  there  was  no  possibility  of 
writers'  cramp  when  using  the  old-fashioned  goose-quill,  and  that  the  whole 
new-fangled  difficulty  was  due  to  the  invention  of  steel  pens.  Research  dis- 
closed, however,  that  scriveners'  palsy  was  also  a  phenomenon  of  the  goose- 
quill  era.  Such  movements  as  those  of  the  hand  grasp  are  naturally  retained, 
and  the  force  of  the  grasp  is  as  a  rule  unimpaired,  although  occasionally  some- 
what weakened.  The  instances  of  local  muscular  wasting  should  probably  not 
be  considered  to  be  in  the  class  of  true  writers'  cramp,  even  as  long-standing 
end  results.  The  data  concerning  electrical  irritability  are,  as  stated 
above,  somewhat  equivocal,  but  that  doubt  is  probably  due  to  the  inclusion  of 


OCCUPATIOX   NEUROSES  279 

neuritic  cases  among  the  supposedly  neurotic  ones  in  a  series  collected  by 
various  workers. 

Cases  which  are  for  convenience  termed  "spastic"  cases  are  nevertheless 
accompanied  by  more  or  less  marked  sensory  symptoms.  Indeed,  sensory 
symptoms  of  some  sort  are  seldom  absent  (and  the  sensory  symptoms  may 
indeed  occur  alone  in  some  instances;  see  below).  The  most  frequent 
sensory  symptoms  include,  besides  a  general  sense  of  distressing  fatigue, 
definite  dull  pains  often  referred  to  various  structures  in  the  hand,  especially 
in  the  metacarpal  region  and  the  wrist.  These  pains  subside  quickly  when 
the  effort  to  write  is  relinquished.  There  may  also  be  local  tenderness  as 
well  as  tingling  and  paraesthesia.  It  is  probable  that  cases  of  various  severe 
pains  running  apparently  in  the  course  of  the  nerves,  with  local  tenderness, 
belong  more  truly  in  a  neuritic  group  of  definitely  structural  origin,  but  may 
be  referred  to  here  because  of  their  association  with  local  spasms.  There 
are  cases  in  which  the  patient  when  not  writing  is  subject  to  local  pains. 
Such  cases  may  be  interpreted  along  lines  of  argument  as  above  stated  as 
phenomena  in  cases  of  local  neuritis.  Cyanosis  has  been  stated  to  occur 
with  such  cases  (Brissaud,  Hallian,  and  Meige).  (See  Anomalous  Group 
below.)  The  outcome  of  these  cases  is  dealt  with  below.  The  milder 
neuralgic  and  tremulous  forms  tend  to  go  over  into  the  spastic  form,  as  well 
as  does  the  paralytic  form,  about  to  be  described.  In  certain  cases  the  spastic 
form  passes  eventually  into  the  paralytic  form. 

(b)  Paralytic  Form. — This  form  is  perhaps  the  typical  impotence  fonc- 
tionelle  des  "ecrivains.  In  this  form  the  subject,  after  essaying  the  use  of  the 
pen,  gets  a  feeling  of  weakness  and  is  unable  to  bear  hard  enough  upon  the 
paper  to  make  properly  legible  marks.  It  would  be  exceedingly  valuable 
if  more  extensive  observations  could  be  made  with  the  Kraepelinian  writing 
apparatus  as  studied  by  Gross;  this  apparatus  permits  registration  of  the 
pressure  and  rapidity  of  writing.  Kraepelin  states  that  in  the  depressive 
cases  of  manic  depressive  psychosis,  there  is  a  slowing  in  speed  of  writing 
and  a  diminution  of  its  size  accompanied  by  a  reduction  in  the  pressure.  It 
is  probably  true  that  numerous  cases  of  writers'  cramp  bear  a  more  general 
resemblance  to  depressive  cases  of  manic  depressive  psychosis  than  they  do  to 
such  conditions  as  the  maniacal  phase  or  the  so-called  catatonic  phases  of 
dementia  praecox.  In  the  latter  conditions,  KraepeHn's  associates  found 
such  writing  as  was  performed  to  be  performed  as  a  rule  without  alteration  or 
punctuated  by  characteristic  sudden  changes  and  interruptions. 

Berger  has  noted  cases  in  which  the  functional  disorder  appears  to  start 
in  the  shoulder  girdle  rather  than  in  the  forearm  and  hand.  The  surgeon 
would  be  tempted  to  see  in  such  cases  instances  of  local  disease,  such  as 
subdeltoid  bursitis;  the  psychiatrist  familiar  with  mild  cases  of  dementia 
praecox  might  be  tempted  to  the  hypothesis  of  a  local  muscular  hj^^ertension 
interpreted  as  a  phenomenon  of  catatonia.  Such  a  condition  would- resemble 
either  true  flexibilitas  cerea  or  the  pseudo-flexibility  of  some  authors.     The 


28o  FATIGUE    AND    OCCUPATION.    NEUROSES 

shoulder  placed  in  a  certain  posture  would  retain  this  posture  in  such  wise  as 
to  defeat  the  proper  exertion  of  the  rest  of  the  extremity.  The  paralytic  form 
does  not  occur  abundantly  in  the  literature  of  writers'  cramp,  but  is  men- 
tioned as  an  end  phase  in  certain  cases. 

(c)  Tremulous  Form. — This  form  has  been  indicated  above.  The 
spastic  and  other  forms  of  the  disease  often  begin  with  tremors  or  show 
tremors  near  the  onset.  The  writing  in  the  pure  examples  of  the  tremulous 
forms  is  said  to  be  not  unlike  the  writing  characteristic  of  paralysis  agitans. 
The  characteristic  handwriting  in  paralysis  agitans  shows,  at  least  in  later 
phases,  a  certain  periodicity,  so  that  in  writing  a  number  of  sentences  the 
manuscript  becomes  tremulous  several  times  only  to  return  to  normality. 
In  the  case  of  multiple  sclerosis,  on  the  contrary,  the  tremors  in  writing 
become  more  and  more  marked  as  the  "intention  becomes  more  settled." 
The  productions  of  the  tremulous  form  have,  however,  in  common  with 
multiple  sclerosis,  the  fact  that  with  the  progressive  execution  of  the  task  the 
ataxia  becomes  coarser.  The  victim  of  multiple  sclerosis,  however,  does  not 
give  up  through  fatigue  or  through  aboulia  as  does  the  victim  of  writers' 
cramp.  One  of  the  synonyms  for  writers'  cramp,  "local  chorea,"  is  in  short 
due  to  the  appearance  of  the  tremulous  form  or  the  tremors  found  in  several 
other  forms.  There  is  no  basis  in  the  literature  for  any  special  relation 
between  writers'  cramp  and  true  chorea.  Work  with  the  KraepeUnian 
writing  registration  apparatus  would  be  of  special  service  in  cases  thought 
to  be  of  this  form. 

{d)  Neuralgic  Form. — Perhaps  the  neuralgic  form  stands  next  to  the 
spastic  form  of  true  writers'  cramp  in  frequency.  In  this  form  evidences 
suggesting  neuritis  are  not  greatly  in  evidence.  The  local  neuralgia  of  inde- 
pendent nature  is  often  found  spreading  from  a  single  point  in  the  hand  and 
to  accompany  movements,  but  the  execution  of  all  other  movements  is  made 
without  pain.  Of  course,  if  the  pain  were  found  following  the  course  of  a 
particular  nerve,  the  chances  are  that  the  diagnosis  of  neuritis  would  be 
preferred.     Associated  with  the  pains  may  be  paraesthesias. 

In  general  it  may  be  observed,  concerning  the  above-mentioned  subforms 
of  true  writers'  cramp,  that  the  movements  may  be  accentuated  when  the 
patient  is  under  observation.  The  examining  physician  has  to  take  this 
into  account  when  evaluating  the  severity  of  a  given  case.  It  must  become 
evident  from  references  in  the  above  paragraphs  that  the  differential  diag- 
nosis is  not  always  easy;  further  data  in  this  direction  will  be  given  below. 
Systematic  examination  of  these  cases  should  show  no  alteration  of  mobility 
or  of  the  touch,  temperature,  and  pain  senses.  Some  experience  of  the  writers 
with  the  Martin  sensory  threshold  tests  seems  to  indicate  that  at  least  in 
some  forms  of  occupation  neurosis  this  very  fmely  quantitative  test  for 
faradic  sensibility  (perhaps  more  finely  quantitative  than  any  other  sensory 
test  so  far  described)  indicates  that  in  writers'  cramp  also  we  may  fmd  it 
desirable  to  resort  to  this  method.     It  may  well  be  that  by  means  of  it 


OCCUPATION   NEUROSES  281 

we  shall  be  able  still  further  to  diminish  the  number  of  cases  of  "true" 
writers'  cramp.  If  future  researches  are  to  yield  eventually  a  small  but 
distinctive  group  of  true  neuroses,  it  is  possible  or  probable  that  they  will  be 
found  in  persons  also  otherwise  "neurotic."  The  discovery  of  cases  with 
increased  reflexes,  with  vasomotor  symptoms,  with  tendency  to  morbid 
apprehensiveness,  to  moodiness  and  variability  of  temperament,  would 
tend  to  bear  out  such  an  hypothesis.  Cases  on  a  so-called  neurotic  basis, 
"hereditary"  cases,  cases  in  which  there  is  overwork  and  undernourishment, 
night  work,  alcoholism,  and  sexual  excess,  are  mentioned,  and  perhaps  belong 
in  this  vaguely  definable  group  of  neuroses. 

In  addition  to  such  general  predisposing  causes,  Bernhardt  mentions  a 
number  of  other  causes  which  doubtless  contribute  more  to  the  growth  of 
writers'  cramp  about  to  be  described  than  they  do  to  true  writers'  cramp. 
The  groups  to  be  described  are  of  a  more  structural  origin;  accordingly  cases 
of  writers'  cramp  are  said  to  follow  injury,  to  be  associated  with  Dupuytren's 
contracture,  to  be  a  partial  phenomenon  of  neuritis,  to  be  due  to  bad  habits 
in  writing,  such  as  using  the  little  finger  for  a  pivot. 

2.  Paralytic  Writers^  Cramp. — This  form  is  intended  to  be  distinct  from 
the  subform  of  paralytic  true  writers'  cramp,  since  the  present  form  is  a 
form  in  which  the  paralysis  of  writing  is  due  to  the  pressure  of  aneurysm  on 
a  section  of  the  ulnar  nerve,  to  local  pressure,  etc.  It  is  conceivable  that 
alterations  in  fine  movements  may  be  brought  about  by  these  pressures  and 
yet  leave  enough  of  the  major  functions  of  the  arm  intact  to  convey  the 
impression  that  we  are  dealing  with  true  writers'  cramp.  The  diagnosis 
must  of  course  depend  upon  other  investigations  than  those  of  the  writing 
power.  Vivian  Poore  found  in  his  series  of  75  cases  six  in  this  group.  In 
full  blown  cases,  there  should  be  electrical  changes  that  might  well  distinguish 
this  group  from  true  writers'  cramp. 

3.  Allied  with  the  paralytic  group  just  described  is  a  group  termed  by 
Poore  ^^ degenerative,''^  occurring  in  nine  cases  in  his  series.  In  this  group, 
the  first  sign  of  the  degenerative  neural  change  is  the  impairment  of  writing 
power;  but  in  cases  of  this  sort,  the  functional  impairment  gradually  or  rapidly 
passes  off,  and  is  supplemented  by  impairment  in  coarser  functions. 

4.  The  spasmodic  group,  comprising  five  cases  in  Poore's  analysis  of  75, 
may  be  of  congenital  origin;  and  in  three  cases  was  found  to  be  due  to  hemi- 
plegia and  in  large  part  related  to  post-hemiplegic  phenomena. 

5.  Neuritic  or  neuralgic  group,  forming  19  cases  in  Poore's  series.  Poore 
states  that  it  is  highly  probable  that  we  have  to  deal  in  this  group  with  a 
mild  form  of  neuritis,  or  at  least  some  form  of  vasomotor  irritability  involv- 
ing one  or  more  of  the  nerves  of  the  affected  arm.  The  symptoms  in  these 
cases' involve  a  wider  area  than  the  writing  muscles.  Sometimes  the  symp- 
toms appear  without  any  endeavor  at  writing.  Characteristic  is  the  appear- 
ance of  tenderness  of  the  nerves.  Many  of  the  patients,  according  to  Poore, 
complain  of  a  queer  feeling  in  the  arm,  especially  at  night,  with  a  constant 


282        '  FATIGUE    AND    OCCUPATION.       NEUROSES 

desire  to  shift  its  position  and  an  inability  to  make  the  arm  comfortable  in 
bed.  Poore  found  in  five  of  his  cases  the  assigned  cause  to  be  excessive 
work  with  the  hand.  In  eight  cases  he  found  history  of  previous  strain  or 
injury,  in  five  cases  worry  and  fatigue;  in  six  cases  he  found  vasomotor 
disturbance. 

6.  Anomalous  cases  often  diagnosticated  as  true  writers'  cramp.  Writing 
disorder  of  the  syphilitic  group  of  disease  of  the  nervous  system  may  some- 
times give  rise  to  this  diagnosis.  Possibly  the  case  of  Brissaud,  Hallian, 
and  Meige  of  so-called  acrocyanosis  associated  with  writers'  cramp  may  have 
been  one  of  early  dementia  praecox.  The  patient  in  this  case,  16  years  of 
age,  made  fantastic  figures,  and  had  in  addition  to  some  psychical  peculiari- 
ties a  marked  cyanosis,  of  his  hands. 

The  disease  usually  lasts  as  long  as  attempts  to  write  are  persevered  in; 
often  when  the  patient  learns  to  write  with  the  other  hand,  the  same  disease 
sets  in  on  the  opposite  side — at  least  in  some  cases.  It  appears  that  improper 
holding  of  the  pen  has  been  stated  to  be  a  cause  of  proportionately  greater 
increase  in  the  disease.  Gowers  has  stated  that  the  disease  tends  to  involve 
more  and  more  muscles  'in  association  with  any  general  weakness  of  the 
nervous  system  which  may  exist.  It  seems  to  be  the  rule  that  sensory 
symptoms  show  a  greater  tendency  to  spread  than  motor.  It  is  clear  that 
the  patient  is  subject  to  anxiety  as  to  his  writing  capacity,  involved  as  it 
is  in  his  earning  power,  which  leads  to  a  piling  up  of  the  agony  in  the  sense 
of  the  American  slang  phrase  to  the  effect  that  the  subject's  actual  dis- 
appointment is  reduced  to  his  being  "rattled."  It  appears  that  in  certain 
cases  rest  has  been  known  to  terminate  the  symptoms. 

The  general  prognosis  is  stated  by  the  books  to  be  often  unfavorable, 
particularly  if  the  disease  has  lasted  for  some  time.  Gowers  states  that 
those  cases  have  a  better  prognosis  in  which  pain  rather  than  spasm  or  paraly- 
sis predominates. 

I.   GENERAL  EXAMINATION  OF  A  SUBJECT  'WITH  'WRITERS' 

CRAMP 

It  seems  well  at  this  point  to  make  some  statement  concerning  the 
general  examination  of  a  patient  with  writers'  cramp  because  the  general 
principles  of  such  an  examination  are  suitable  for  examining  victims  of  other 
forms  of  occupation  neurosis.  Following  the  general  tendency  of  Vivian 
Poore  to  regard  the  disease  as  perhaps  more  likely  than  not  to  be  really  of 
structural  origin,  Henry  Head  has  offered  valuable  paragraphs  upon  the 
principles  of.  such  a  general  examination.  Head  states  that  every  patient 
complaining  of  an  occupation  neurosis  should  undergo  a  complete  examination 
as  if  for  life  insurance.  In  other  words,  the  patient's  heredity,  past  and  pres- 
ent history,  to  say  nothing  of  his  temperament  and  character,  must  be 
finically  investigated.     A  routine  neurological  examination  must  be  per- 


OCCUPATION   NEUROSES  283 

formed  with  a  special  search  for  wasting  processes  as  well  as  tremors  and 
disabilities  of  coordination.  The  examination  must  be  so  thorough  as  to 
rule  out  arteriosclerosis,  renal  disease,  and  various  diatheses. 

Head  makes  a  great  point  of  examining  the  functions  of  the  two  arms 
and  of  all  the  rest  of  the  body,  particularly  its  upper  part,  in  the  nude. 
Asymmetry  in  postures  assumed  at  command  may  easily  betray  unilateral 
muscular  weakness.  Defective  action  of  the  trapezius,  the  levator  anguli 
scapulae,  rhomboids,  and  serratus  magnus  is  thus  made  manifest  if  it  exists. 
The  general  tests  for  motility  are  then  applied. 

There  follows  a  general  examination  of  sensibility  with  particular  atten- 
tion to  the  possible  tenderness  of  nerve-trunks.  Head  emphasizes  the  neces- 
sity of  testing  the  tenderness  of  the  coordinate  nerve-trunks  of  the  two  sides 
because,  as  he  says,  every  nerve-trunk  normally  shows  some  tenderness. 
The  following  statement  from  Head  is  interesting  enough  to  quote: 

"This  examination  requires  care,  because  normal  nerve- trunks  are  somewhat  tender, 
and  it  is  only  by  comparison  of  one  side  with  the  other  that  we  can  arrive  at  any  useful  con- 
clusion. The  patient  stands  facing  the  examiner,  with  both  hands  resting,  palms  upward, 
on  the  examiner's  shoulders.  It  is  important  that  the  patient's  arms  should  be  really  at 
rest,  and  as  free  from  all  muscular  efforts  as  possible.  The  physician  then  examines  the 
nerve-trunks  of  both  limbs  simultaneously  by  means  of  gentle  pressure  on  the  ulnars  behind 
the  olecranon,  on  the  musculo-spirals  at  the  inner  borders  of  the  supinator  longus,  and  on 
the  median  at  the  elbows,  on  the  inner  side  of  the  biceps  tendon.  The  simultaneous  exam- 
ination of  the  medians  can  only  be  made  if  the  examiner  crosses  his  hands.  If  the  ex- 
amination of  the  nerve-trunks  on  the  two  sides  be  made  simultaneously,  there  is  greater 
likelihood  of  the  pressure  being  equal;  and  if  the  examiner  find  a  distinct  difference  in  the 
tenderness  of  the  nerves,  he  is  justified  in  recording  it  as  a  symptom  of  importance.  The 
patient  is,  of  course,  in  ignorance  of  the  object  of  the  examination,  and  when  the  nerve- 
tenderness  is  well  marked  his  response  to  a  gentle  pressure  of  the  thumb  is  startling  alike  to 
examiner  and  examinee.  This  comparison  of  the  two  sides  can  only  be  trustworthy  when 
the  nutrition  of  the  two  is  equal;  if  one  arm  be  wasted,  the  comparison  is  no  longer  possible. 
The  search  for  tender  nerves  is  important  in  all  these  cases;  and  not  seldom  one  of  the 
palmar  twigs  of  the  medium  or  ulnar  is  found  to  be  tender,  or  tenderness  is  detected 
along  the  course  of  the  suprascapular,  circumflex,  or  anterior  thoracic  nerves." 

Careful  sensory  tests  should  follow  with  special  reference  to  their  differ- 
ences in  coordinate  parts  of  the  two  limbs.  The  orthopedic  group  of  dis- 
orders must  be  looked  for  in  the  bones,  joints,  and  ligaments. 

Many  authors  have  mentioned  dififerences  in  temperament  in  these  cases. 
We  may  again  quote  from  Head  in  this  matter: 

"The  patient,  still  stripped  to  the  waist  in  a  warm  room,  should  now  be  made  to  carry 
out  the  particular  act  of  which  he  complains.  If  it  be  to  write,  give  him  a  sheet  of  paper 
and  a  good  pen,  see  that  he  has  a  comfortable  chair  and  table,  and  ask  him  to  write  his 
name  and  address,  and  the  date.  A  great  deal  may  often  be  learned  by  watching  his 
attempts  to  perform  the  deranged  action.  Occasionally  nothing  amiss  is  to  be  detected, 
except  perhaps  that  the  writing  may  be  produced  rather  slowly.  The  patient  may  tell  you 
that  the  effort  to  write  causes  pain;  but,  so  far  as  any  change  in  the  mode  of  production  or 
in  the  product  itself  is  concerned,  there  is  nothing  amiss.  This,  of  course,  is  important  both 
in  diagnosis  and  prognosis.     At  the  other  end  of  the  scale  is  the  man  who  is  scarcely  able  to 


284  FATIGUE    AND    OCCUPATION.    NEUROSES 

make  a  mark  upon  paper;  whose  efforts  are  accompanied  by  most  tumultuous  movements 
of  the  shoulder,  who  is  obliged  to  fix  his 'arm  securely  before  beginning  to  write;  who 
grasps  the  pen  with  all  his  might,  and  perhaps  drips  with  perspiration  as  he  makes  an 
abortive  attempt  to  sign  his  name." 

Electrical  examinations  have  been  mentioned  above.  Reaction  of  de- 
generation is  never  found  in  uncomplicated  cases  of  occupation  neurosis. 
Diminution  in  galvanic  excitability  is  said  to  be  confined  to  the  small  muscles 
of  the  hand  and  to  affect  the  first  dorsal  of  the  interosseous  group  more 
frequently. 

Differential  Diagnosis. — The  diagnosis  of  a  disease  due  to  occupation 
seems  to  be  an  obvious  matter  in  instances  of  writers'  cramp.  The  diffi- 
culty lodges,  not  so  much  in  placing  the  condition  in  the  group  of  occupation 
diseases  as  in  choosing  the  condition  fundamental  in  the  particular  case. 
This  latter  choice  usually  lies  between  the  supposition  of  a  true  neurosis  in 
the  sense  of  a  disease  not  primarily  due  to  local  structural  changes,  and  one 
or  other  forms  of  neuritis,  neuralgia,  myositis,  myalgia,  or  other  local  disease. 
As  our  description  has  abundantly  shown,  the  very  nature  of  the  disease  is 
in  question,  and  the  description  is  spht  along  the  familiar  lines  of  controversy 
between  structurahsts  and  functionalists  in  neuropathology. 

The  fact  seems  to  be  that  the  majority  of  all  cases  of  writers'  cramp 
(which  are  said  by  some  to  form  nine-tenths  of  all  cases  of  occupation  neuro- 
sis) are  cases  which  fall  outside  the  pale  of  the  true  neuroses.  It  is  well  to 
concede  that  there  may  be  a  small  group  of  truly  functional  cases,  and  in 
any  event  to  remember  that  in  accordance  with  well-known  principles,  the 
range  of  functional  symptoms  in  a  given  case  may  exceed  the  range  of  the 
immediately  structural  symptoms.  Treatment  may  be  governed  accord- 
ingly. Taking  for  granted  that  the  case  presenting  itself  for  treatment  has 
in  practically  all  cases  made  a  diagnosis  before  resort  to  the  physician,  the 
physician  must  launch  his  differential  diagnosis  in  the  first  place  in  the  direc- 
tion of  excluding  constitutional  disease  in  which  the  writing  defect  may  be 
merely  the  most  striking  phenomenon  of  weakness  because  perhaps  it  affects 
the  earning  power  of  the  subject.  Assuming  that  such  constitutional  dis- 
eases as  have  been  mentioned  above  have  been  excluded  by  the  most  careful 
general  medical  and  neurological  examination,  it  would  seem  wise  to  include 
a  careful  psychopathological  analysis  from  the  diagnostic  point  of  view. 
The  books  have  probably  not  emphasized  sufficiently  the  psychiatric  possi- 
bilities in  this  direction  and  particularly  mild  depressive  states  which  may  or 
may  not  be  distinguishable  in  a  given  case  from  the  phenomena  of  psycho- 
neurosis.  If  constitutional  disease,  the  common  neurological  affections  and 
psychiatric  conditions  of  a  pronounced  character  can  be  excluded,  the  process 
of  diagnosis  must  begin  to  deal  more  particularly  with  orthopedic  conditions, 
such  as  osteitis,  periosteal  changes,  tenosynovitis,  synovitis,  arthritis  and 
various  forms  of  myositis  and  other  myopathy.  The  discovery  of  various 
degrees  of  these  orthopedic  conditions  does  not,  according  to  some  authors, 


OCCUPATION    NEUROSES  285 

always  mean  that  the  entire  condition  is  an  orthopedic  one.  It  may  accord- 
ingly be  well  to  hold  in  mind  that  osteopathy  or  myopathy  is  part  and  parcel 
of  a  more  general  process  involving  also  the  nerves,  and  that  any  or  all  of 
these  changes  may  be  associated  with,  preceded  by,  or  followed  by  neurotic 
changes  in  the  sense  of  purely  functional  conditions. 

The  analysis  must  next  consider  the  neuropathies,  general  and  local. 
If  we  should  adopt  the  triple  classification  of  James  Mackenzie  of  structural, 
functional,  and  reflex  symptoms,  especially  structural,  functional,  and  reflex 
pain,  we  must,  perhaps,  exclude  the  so-called  reflex  pain  from  consideration 
inasmuch  as  it  has  not  been  shown  that  conditions  in  viscera  can  lead  to  such 
a  condition  as  writers'  cramp.  However,  if  central  nervous  conditions  suitable 
for  the  production  of  reflex  pain  could  be  brought  about  by  local  disease  in 
the  central  nervous  axis,  then  it  is  conceivable  that  there  might  be  cases  of 
painful  writers'  cramp  of  central  origin.  We  have  not  encountered  such 
cases  in  the  literature.  The  symptoms  would  then  in  general  reduce  in  the 
sense  of  Mackenzie  to  functional  and  structural  ones;  probably  in  most  cases 
there  is  a  combination  of  these.  Despite  the  tendency  of  the  writers  to  look 
for  psychiatric  causes  in  this  affection,  we  have  become  more  and  more 
enamoured  of  what  might  be  called  the  peripheral  hypothesis,  and  to  agree 
with  the  general  modern  tendency  to  discover  in  these  cases  neuritis  in  greater 
or  less  degree.  An  enumeration  of  conditions  which  have  been  or  may 
readily  be  mistaken  for  true  writers'  cramp  bears  out  this  general  tendency. 

First  among  the  conditions  which  should  if  possible  be  differentiated 
from  the  true  occupation  neurosis  is  what  may  be  termed  occupation  neuritis, 
in  which  there  will  be  found  sensory  changes  (tenderness  of  nerve-trunks, 
motor  changes),  paralysis,  tremor,  etc.,  and  electrical  changes  (in  the  ex- 
treme case,  reaction  of  degeneration).  Neurasthenic  and  hysterical  patients 
are  among  those  who  may  eventually  exhibit  writers'  cramp,  and  it  may 
accordingly  be  difficult  to  pull  apart  the  effects  of  the  underlying  general 
neurosis  and  the  particular  phenomenon  of  the  cramp,  particularly  in  hys- 
terical cases  in  which  there  are  so  often  unilateral  symptoms.  Among 
diseases  which  have  given  rise  to  errors  in  diagnosis  may  be  mentioned  mul- 
tiple sclerosis,  tabes — notably  brachial  tabes,  hemiplegia  of  a  gradual  devel- 
opment (the  thrombotic  type),  paralysis  agitans,  general  paresis.  A  number 
of  psychiatric  conditions  need  mention  since  the  writing  disorder  may  emerge 
from  them  as  one  of  the  most  striking  symptoms:  brain  tumor,  brain  abscess, 
senile  dementia,  alcoholic  mental  disease,  post-infectious  psychosis,  chorea, 
the  melancholic  and  catatonic  phases  of  certain  mental  diseases,  congenital 
agraphias,  and  so  on.  Dupuytren's  contraction,  acroparaesthesia,  and  even 
Raynaud's  disease  may  need  to  be  thought  of.  A  fundamental  study  of  a 
differential  diagnosis  of  these  disorders  would,  in  fact,  lead  to  including  prac- 
tically the  entire  range  of  nervous  and  mental  disorders,  together  with  a 
large  group  of  orthopedic  and  general  medical  disorders. 

The  Range  of  Treatment. — The  range  of  treatment  in  occupation  neuroses 


286  FATIGUE    AND    OCCUPATION.       NEUROSES 

is  wide,  corresponding  to  the  hypotheses  adopted  by  authors  concerning 
cases.  On  the  general  hypothesis  of  fatigue,  a  number  of  bits  of  apparatus 
have  been  constructed  which  permit  writing  to  be  performed  by  the  use  of 
somewhat  different  muscles.  It  is  probable  that  no  one  of  these  pieces  of 
apparatus  has  been  extremely  effective.  To  meet  local  conditions,  special 
gymnastic  movements  have  been  prescribed,  active  and  passive  movements, 
as  well  as  passive  movements  executed  by  the  non-affected  hand.  Work 
with  Zander  apparatus  and  massage  has  been  tried,  as  well  as  galvanic  and 
occasionally  faradic  electricity.  Hydrotherapy  has  come  in  for  a  share  of 
attention.  Bier's  hypertemic  method  has  been  employed.  The  relief  of 
irritation  as  by  counter-irritation,  and  the  use  of  the  cautery,  have  been 
counselled,  as  well  as  muscle  stretching.  There  is  a  large  group  of  hygienic 
counsels;  attention  to  the  eyes,  condition  of  the  nerves  and  condition  of  the 
muscles,  schemes  for  removal  of  the  difficulty  by  suggestion  or  by  subtler 
methods  of  psychotherapy  and  by  psychoanalysis.  Re-educational  processes 
are  mentioned,  as  well  as  the  so-called  education  of  the  will.  There  is  a 
group  of  recommendations  beginning  with  rest.  The  use  of  the  other  hand, 
the  use  of  the  typewriter  instead  of  pen  and  paper,  and  mirror  writing  (with 
the  object  of  the  correction  of  early  acquired  habits)  are  noted  in  the  litera- 
ture. There  is  a  group  of  suggestions  from  the  pharmacological  side  ranging 
from  the  local  injection  of  carbolic  acid  (doubtless  founded  on  the  results  in 
certain  cases  of  trigeminal  neuralgia  with  alcohol)  to  the  exhibition  of  various 
tonics  and  other  drugs.  Both  excitants  and  sedatives  are  mentioned;  we 
have  noted  the  following  drugs:  strychnine,  atropine,  bromides,  narcotics, 
quinine,  valerianate  of  zinc,  arsenic,  iodoform,  gelsemin;  zinc  phosphate, 
Gowers  is  incHned  to  recommend  above  all  the  rest.  He  is  wilhng  to  counsel 
writing  with  the  other  hand,  although  it  is  said  in  50  per  cent,  of  all  cases 
the  cramp  occurs  in  the  other  hand  after  a  time.  Gowers  thinks  that  stimu- 
lants are  superior  to  sedatives  in  the  general  treatment  of  these  cases,  but 
naturally  employs  sedatives  in  various  instances  in  which  neuralgia  is 
predominant. 

II.  OTHER  MANUAL  NEUROSES 

First  among  these  stands  typewriters'  cramp,  a  modern  disease  which 
comes  on  either  independently,  or  after  the  therapeutic  substitution  of  type- 
writing for  manuscript  which  is  occasionally  counselled.  Typewriters'  cramp 
does  not  supervene  immediately,  but  it  appears  that  it  may  occur  within  a 
period  of  weeks  or  months  after  the  handwriting  has  been  given  up.  This 
disease  appears  to  be  extremely  r^re;  Head  has  personally  observed  but  one 
case.  Dr.  W.  E.  Paul  of  Boston  has  had  a  case.  Typewriters'  cramp  is  as  a 
rule  bimanual. 

Telegraphers'  Cramp. — This  disease  appears  to  be  rare,  whether  in  form  of 
tremor,  or  paresis,  or  pain.  One  of  Vivian  Poore's  cases  may  be  abstracted 
as  follows: 


OCCUPATION    NEUROSES  287 

A  man,  aged  39,  had  worked-a  Morse  key  for  19  years.  He  had  as  much 
difficulty  in  writing  as  in  telegraphing,  and  it  was  noticeable  that  all  delicate 
acts — such  as  shaving,  holding  a  teacup,  or  wielding  a  salt-spoon — were  seri- 
ously impeded  by  tremor.  The  tremor  affected  all  the  muscles  of  the  right 
upper  limb,  including  the  pectoralis  major;  but  it  was  most  marked  when  the 
hand  was  prone  in  the  telegraphist's  position.  The  median  and  musculo- 
spiral  nerves  on  the  right  side  were  distinctly  tender. 

This  case  might  certainly  be  interpreted  to  signify  a  more  general  dis- 
order than  that  in  the  hypothetic  association  sense  for  the  manipulation  of 
the  Morse  key.  The  literature  contains  a  discussion  as  to  whether  the 
Morse  key  or  the  Hughes  key  is  the  more  likely  to  bring  about  telegraphers' 
cramp. 

Pianists'  Cramp. — Cases  of  Poore,  de  Lepinay,  and  Riseau  are  mentioned. 
The  Hterature  indicates  that  the  disease  occurs  in  beginners  rather  than  in  vir- 
tuosi. A  case  of  de  Lepinay  quoted  by  Head  was  that  of  a  musician  who  at 
first  could  not  extend  the  little  finger  of  the  right  hand  in  playing  the  oboe. 
Later,  the  ring  finger  could  not  be  extended,  and  trouble  in  playing  the  piano 
followed.  Examination  demonstrated  that  there  was  also  difficulty  in  sev- 
eral other  delicate  acts  performed  by  these  muscles,  to  such  an  extent  that  it 
may  be  held  that  this  case  was  one  of  musculospiral  neuritis. 

Violinists'  Cramp. — The  characteristic  digital  corns  of  the  violinist 
occasionally  become  tender  and  cause  pain  that  radiates  up  the  arm  and 
prevents  firm  pressure  of  the  fingers  on  the  strings.  Such  cases  would  have 
to  be  regarded  as  pseudo-cramp  cases.  True  cases  of  occupation  neurosis  in 
violin  players  and  players  of  other  stringed  instruments  appear  to  be  extremely 
rare. 

Sewing  Cramp  and  Scissors  Cramp. — These  are  rare  forms  of  manual 
occupation  neuroses.  The  latter  form  appears  under  some  circumstances  to 
be  due  to  actual  neural  and  muscular  atrophy  produced  by  pressure  from  the 
scissors  upon  the  thenar  eminence. 

Hammermen's  Cramp. — Head  points  out  that  many  cases  of  supposed 
Hammermen's  cramp  are  really  otherwise  to  be  explained.  Thus  the 
hephaestic  palsy  of  Frank  Smith,  Head  regards  as  a  cerebral  hemiplegia  or 
monoplegia  occurring  in  a  hammerman.  Head  believes,  however,  that  there 
is  a  condition  which  approaches  a  true  occupation  neurosis,  or  is  in  any  event 
a  distinct  clinical  entity. 

I  have  seen  many  blacksmiths  and  men  accustomed  to  the  use  of  a  hammer  who  com- 
plained that  they  could  not  hold  it  in  one  or  other  hand.  But  in  every  case  the  dissability 
depended  on  the  presence  of  pain  in  the  neighborhood  of  the  elbow,  evoked  by  attempting 
to  grasp  anything  firmly  in  the  hand.  This  condition  seems  to  be  a  distinct  clinical  entity 
of  frequent  occurrence,  but,  so  far  as  I  have  been  able  to  discover,  it  has  not  been  definitely 
described.  Many  cases  of  "hammermen's  cramp"  seems  to  have  been  instances  of  this 
disease,  which  I  believe  to  be  closely  allied  to  meralgia  paraesthetica  in  the  leg  (Bernhardt's 
disease). 

The  patient  begins  to  complain  of  pain  situated  over  the  insertion  of  the  long  extensors 


288  FATIGUE    AND    OCCUPATION   NEUROSES 

of  the  fingers  just  below  the  external  condyle.  The  pain  is  never  entirely  absent,  but  is 
greatly  increased  when  he  attempts  to  grasp  with  the  hand  of  the  affected  extremity. 
Should  the  patient's  occupation  necessitate  any  movement  in  which  the  long  extensors  par- 
ticipate, he  will  complain  of  professional  disability.  Thus,  T  have  seen  a  blacksmith,  a 
ladler  of  metal  for  stereotyping,  and  a  Government  clerk,  all  of  whom  suffered  from  this 
complaint;  the  first  could  not  use  his  hammer,  the  second  his  ladle,  and  the  third  his  pen, 
without  bringing  on  the  pain  so  severely  that  work  became  impossible.  The  Government 
clerk  gave  the  following  history  of  the  onset  of  pain.  Coming  home  one  winter  night  from 
a  week-end  in  the  country,  he  arrived  at  the  station  to  find  no  cab.  He  was  therefore 
obliged  to  carry  a  heavy  bag  some  distance  to  his  home.  Next  morning  he  noticed 
pain  over  the  extensors  of  the  forearm,  which  was  easier  when  the  arm  was  flexed.  It 
was  greatly  increased  by  writing  or  by  handing  a  plate;  grasping  the  spade  while  garden- 
ing produced  severe  pain.  It  gradually  improved  to  such  an  extent  that  he  was  free  from 
pain  unless  he  wrote  for  long  periods  or  performed  any  act  which  necessitated  grasping. 
In  these  cases  the  pain  seems  also  to  produce  a  curious  inhibiting  effect  upon  the  strength 
of  the  grasp,  so  that  the  patient  complains  that  his  hand  'feels  weak;'  and  yet  there  is 
no  weakness  of  any  muscles  of  the  hand.  Extension  is  both  painful  and  difficult,  and  so 
the  wrist  and  fingers  are  no  longer  fixed,  and  the  flexors  cannot  act  for  want  of  their 
normal  support.  This  was  well  seen  in  the  ladler  of  metal,  who  was  no  longer  able  to 
employ  his  right  hand  as  a  fulcrum  when  using  his  long  handle. 

"I  believe  this  condition  is  produced  by  injury  to  the  nerve-twigs  which  pass  through 
the  extensors  to  come  to  the  surface  just  below  the  external  condyle.  This  spot  is  in- 
tensely tender  to  deep  pressure,  and  there  is  generally  a  patch  of  tenderness  to  the  point 
of  a  dragged  pin,  with  or  without  a  little  diminution  in  cutaneous  tactile  sensibility,  over 
a  patch  a  few  inches  in  length  situated  just  below  the  external  condyle.  No  other  nerve 
trunks  are  tender,  and  the  muscular  reactions  do  not  shew  any  change. 

"Complete  rest  of  the  arm  with  blisters  applied  to  the  tender  spot  will  generally  cure 
the  disease  in  6  weeks.  But  it  is  liable  to  drag  on  if  the  arm  is  used,  and  may  fall  into 
a  chronic  intractable  condition." 

Granite  Cutters'  Cramp. — We  have  had  the  opportunity  of  examining  a 
case  of  cramp  in  which  an  apparent  occupation  neurosis  was  produced  at  the 
end  of  15  years'  of  work  with  a  pneumatic  tool  used  in  quarrying.  This 
tool  caused  considerable  jarring  of  the  arm.  The  patient  when  seen  had  had 
6  months  of  symptoms.  The  first  symptom  was  pain  in  the  forearm,  radi- 
ating back  to  a  point  above  the  elbow.  The  pain  had  grown  progressively 
worse,  and  the  patient  had  thought  of  quitting  work  owing  to  a  real  or  imag- 
ined difficulty  in  grasping  the  hammer.  The  patient  had  ceased  work  with 
this  tool,  4  months  before  our  observation,  but  the  pain  had  continued. 
The  case  was  complicated  by  worry  over  the  payment  of  bills  and  the  possi- 
bility of  insurance.  Wassermann  reaction  was  positive.  We  found  that  a 
pain  in  the  elbow  would  appear  when  the  hand  was  flexed.  A  similar  ache 
would  appear  at  night.  Early  in  the  disease,  the  patient  had  had  a  certain 
degree  of  numbness  of  the  ring  and  little  fingers.  The  patient  found  that  he 
could  flex  his  forearm  if  in  the  full  position  of  supination  or  pronation;  but 
that,  if  the  hand  was  held  in  a  semi-prone  posture,  he  could  not  flex  his  fore- 
arm without  pain.  This  semi-prone  position  of  the  arm  was  the  position 
characteristically  maintained  while  working  with  the  pneumatic  tool.  Exami- 
nation of  the  sensibility  of  the  skin  gave  a  negative  result  to  ordinary  tests. 


OCCUPATION   NEUROSES  289 

nor  was  there  any  abnormal  tenderness  over  nerve-trunks.  The  grasp  of 
the  left  hand  stood  to  that  of  the  right  as  42  to  38.  We  were,  however,  able 
to  demonstrate  by  means  of  the  Martin  sensory  threshold  test  for  faradism, 
that  there  was  still  a  slight  degree  of  anaesthesia  of  the  hand,  most  marked  in 
the  thumb  and  little  fingers.  It  is,  of  course,  possible  that  this  electrical 
anaesthesia  is  in  some  sense  functional,  but  it  seemed  more  likely  that  it 
depends  upon  a  structural  neuritic  disorder.  Our  experience  with  this  case 
gives  an  intimation  of  what  finer  examinations  may  bring  out  in  various 
cases  of  other  forms  of  occupation  neuroses,  notably  in  writers'  cramp. 
Cases  in  which  no  anaesthesia  can  be  demonstrated  with  the  methods  ordi- 
narily available  to  the  clinician  may  yield  results  with  this  test.  Upon 
inquiry,  we  learn  that  stonecutters  not  infrequently  show  a  disease  of  this 
general  character. 

Cigarmakers'  Cramp. — In  Boston,  and  doubtless  elsewhere  where  cigar- 
making  is  an  habitual  occupation,  cases  of  cigarmakers'  cramp  appear  from 
time  to  time.  They  have  come  to  the  attention  of  the  Industrial  Accident 
Board  in  Massachusetts,  but  it  cannot  be  said  that  the  condition  has  as  yet 
been  reduced  to  a  well  understood  entity.  We  had  the  experience  of  a  case 
characterized  by  a  somewhat  curious  feature;  just  prior  to  each  of  several 
attacks  of  mania  in  the  psychosis  termed  by  Kraepelin  manic  depressive 
insanity,  difficulty  in  rolling  the  tobacco  leaves  appeared,  being  the  first  sign 
or  species  of  aura  for  these  attacks. 

Artists'  Cramp. — A  form  of  disease  doubtless  not  truly  belonging  to  the 
occupation-neurosis  group  was  observed  by  us  in  a  painter,  who  was  the  victim 
of  a  psychoneurosis  characterized  by  irritability ,  hypochondria,  insomnia,  and 
an  inability  combined  with  a  persistent  desire  to  work;  with  the  onset  of  the 
aboulia,  the  pain  and  incapacity  to  use  the  brush  would  occur.  The  artist 
would  then  give  up  his  work  for  a  time.  Upon  recovery  from  the  psycho- 
neurosis  under  treatment  by  means  of  rest,  hydrotherapy,  and  argumentation, 
the  patient  entirely  recovered  his  capacity  to  use  the  brush. 

m.  OTHER  FORMS  OF  OCCUPATION  NEUROSES 

There  is  a  small  group  of  what  might  be  termed  pedal  neuroses,  of  which 
may  be  mentioned  dancer's  cramp,  the  most  frequent  or  only  form  of  which 
known  is  that  in  the  toe  dancer.  In  the  list  given  above  are  several  examples 
of  still  other  forms,  such  as  buccal,  laryngeal,  and  the  like. 

IV.  GENERAL  PROGNOSIS  AND  TREATMENT 

It  must  be  obvious  from  the  above  account  that  the  diagnostic  problems  of 
the  occupation  neurosis  group  are  almost  inextricably  mixed  with  those  of 
various  neuropathies  and  myopathies  associated  with  different  forms  of  occu- 
pation.    Accordingly  the  most  essential  problem  to  solve  is  that  of  diagnosis 
19 


290  FATIGUE    AND    OCCUPATION.    NEUROSES 

in  a  given  case.  The  experience  of  almost  every  neurologist  is  likely  to  be 
rather  meager  in  this  field.  The  careful  investigation  and  report  of  all  cases 
of  occupation  neuropathy  and  neuritis  may  be  recommended,  so  that  as  the 
years  pass  a  more  and  more  comprehensive,  systematic  study  of  these  allied 
conditions  may  be  made.  As  in  the  case  of  stonecutters'  disease  mentioned 
above,  it  is  possible  that  the  Wassermann  reaction  may  be  of  service  in  eluci- 
dating certain  tendencies  to  neuritis.  And  it  may  be  here  that  such  a  theory 
as  the  Ersatz  Theorie  of  Edinger  may  have  its  application.  According  to  this 
theory,  functional  overuse  or  a  part  may  for  intimate  metabolic  reasons  pro- 
duce or  permit  structural  changes. 

As  also  noted  above,  a  number  of  cases  disappear  from  the  occupation 
neurosis  group  and  reappear  in  the  group  of  the  frank  psychoses. 

Aside  from  various  pseudo-forms  of  occupation  neurosis  (of  which  a  suf- 
ficient list  has  been  given  under  the  heading,  "Writers'  Cramp"),  the  true 
occupation  neuroses  form  a  group  whose  prognosis  is  on  the  whole  not  good 
if  we  make  it  our  aim  to  send  the  patient  back  with  his  original  capacity 
to  perform  the  function  with  which  he  now  has  difficulty.  The  prognosis  as 
to  a  perfect  recovery  of  the  original  function  is  decidedly  not  good.  Also, 
in  sundry  instances,  the  prognosis  is  unfavorable  with  respect  to  the  success 
of  a  substitution  of  some  nearly  allied  function,  such  as  typewriting  for  manu- 
script. On  the  whole,  it  would  seem  wiser  to  take  steps  at  once  to  change 
the  occupation  somewhat  radically  if  the  diagnosis  of  true  occupation  neuro- 
sis can  be  made  reasonably  certain. 

As  to  treatment,  the  general  counsel  of  rest  from  the  occupation  in  ques- 
tion is  well-nigh  universal.  Naturally,  if  the  diagnosis  be  incorrect,  the 
counsel  "rest"  may  be  also  decidedly  incorrect. 

Substitution  of  a  new  form  allied  to  the  old  is  the  second  general  prescrip- 
tion. It  would  seem  very  unlikely  that  there  should  be  an  endless  chain  of 
disabilities  ensuing  upon  substitutions  of  new  forms  of  occupation  unless 
there  is  some  more  fundamental  form  of  disorder  at  the  bottom  of  the  condi- 
tion, such  as,  for  example,  a  psychoneurotic  or  frankly  psychopathic  condi- 
tion. In  a  country  like  the  United  States,  wherein  it  seems  to  be  almost 
the  universal  habit  to  change  occupations  more  or  less  frequently,  the  secur- 
ing of  substitute  occupations  is  perhaps  not  so  difficult  as  in  a  country  of 
more  stable  social  conditions.  We  hardly  possess  in  the  United  States  such 
conditions  as  hold  in  the  greatly  extended  civil  service  of  Great  Britain. 

If,  however,  rest,  with  or  without  a  substitution  of  a  new  form  of  occupa- 
tion, cannot  be  executed,  or  if  the  disability  is  such  as  to  be,  as  it  were, 
more  irritative  than  destructive  to  the  performance,  then  it  might  be  inquired 
whether  gymnastics  and  exercise  would  not  be  of  benefit.  It  does  not  appear 
that  in  cases  of  true  occupation  neurosis  gymnastic  exercises  have  been  of 
any  benefit. 

A  list  of  drugs  used  in  writers'  cramp  has  been  given  above  and  need  not 
be  repeated  here.     The  best  general  injunction  accordingly  in  a  case  of  sup- 


OCCUPATION   NEUROSES  291 

posed  occupation  neurosis  is  that  the  diagnostician  shall  endeavor  by  all 
means  to  prove  that  case  is  not  one  of  occupation  neurosis.  The  chances 
are  very  good,  as  the  above  account  has  intimated,  that  the  expert  diag- 
nostician will  prove  that  the  majority  of  these  cases  are  actually  neuritides, 
or  examples  of  neuropathies,  myopathies,  arthropathies,  or  other  local  forms 
of  disorder  affecting  finer  acquired  habitual  movements.  Thus,  the  same 
general  tendency  which  we  observed  in  neuropathology  at  large  obtains  in 
this  field  also,  namely,  that  the  neuroses  in  the  sense  of  functional  conditions 
tend  to  disappear  into  conditions  in  some  sense  structural.  To  be  sure,  the 
structural  conditions  in  question  may  not  need  to  be  overt  examples  of  nerve 
or  muscle  wasting  or  of  microscopically  demonstrable  fatty  degeneration, 
but  the  technique  of  the  future  will  doubtless  prove  able  to  demonstrate 
finer  forms  of  physical  and  chemical  disorder  which  will  serve  better  to  ex- 
plain both  neuroses  in  general  and  the  small  but  perturbing  group  of  occupa- 
tion neuroses. 

A  note  should  be  made  of  a  new  and  practical  phase  into  which  the  occu- 
pation neurosis  question  passes  through  the  enactment  of  various  workmen's 
compensation  acts.  Problems  of  a  most  intricate  nature  come  up  in  connec- 
tion with  arbitration  boards  dealing  with  these  questions.  The  whole  topic 
of  simulation  enters  to  obscure  the  issue.  It  is  too  early  to  speak  of  the 
practical  effect  of  these  acts  in  this  country.  It  is  probable  that  the  theory 
of  the  condition  will  be  greatly  benefited  by  the  careful  expert  examinations 
which  will  be  performed  in  these  cases.  We  have  already  noted  a  tendency 
to  greater  care  in  these  examinations  as  a  result  of  the  work  of  a  commission 
like  the  Industrial  Accident  Board  of  Massachusetts. 

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Lewandowsky's  Handbuch  der  Neurologie;  as  also  in  the  article  of  Henry  Head  in  the 
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OCCUPATION    NEUROSES 


293 


von  Gefasserkrankungen.     Deut.  Zeit.  fiir  Xenenheilkunde,  1898,  XIII,  page  i. 

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Paris,  1906,  2,  S.,  XII,  19. 
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Un  cas  rare  de  spasme  fonctionnel  de  I'e-xtremite  inferieure.     Rev.  Neur.,  Paris, 

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Head,  Henry. — Allbutt  and  Rolleston's  System  of  Medicine,  1910,  Vol.  VIII,  667.     Occupa- 
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97,  XXIX,  139. 
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mit  Hysteric.     Deut.  Zeit.  f.  Nervenk,  1905,  XXX,  103. 
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heitcD,  1913. 
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reeducation.     Nouv.  Icon.   Salpetr.,  1905,  XVIII,   215,  et  IX  Congr.   med.  int., 

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Wien.  klin.  Woch.,  XXI,  Oct.  8,  1908,  1414. 
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294  FATIGUE   AND    OCCUPATION.    NEUROSES 

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Rev.   Neur.,    1908.     Gymnastique   en    Miroir.     Prog,   med.,    1901,   3,   S.,    XIII, 

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Wien.  klin.  Rdsch.,  1900,  XIV,  411. 
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Med.  Jour.,  1895,  LXI,  69. 
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405. 
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491. 
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Jg,  24,  page  462. 


OCCUPATION   NEUROSES  295 

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page  218. 
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Jg,  10,  page  245. 
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Xouv.  Icon,  de  la  Salpetr.,  Annee  14,  No.  i,  1901,  page  149. 
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DIVISION  IV 

Occupational  Affections  of  the  Nose,  Mouth,  Throat, 
Eye,  and  Ear 

CHAPTER  I 

OCCUPATIONAL  AFFECTIONS  OF  THE  NOSE,  MOUTH 
AND  THROAT 

BY  T.  M.  LEGGE.  M.  D..  London.  England 

I.  The  Effect  of  Dust  and  Fumes  on  the  Upper  Air  Passages 

The  bichromates  are  one  example  of  corrosive  chemical  action  causing 
acute  inflammation  of  the  upper  air  passages  and  progressing  to  a  definite 
pathological  lesion  in  perforation  of  the  septum  of  the  nose.  Almost  pre- 
cisely similar  corrosive  action  is  exhibited  after  inhalation  of  the  intensely 
irritating  dust  of  white  arsenic,  or  of  compounds  into  which  arsenic  largely 
enters,  such  as  arsenite  of  copper  (Scheele's  green),  aceto-arsenite  of  copper 
(emerald  or  Paris  green),  and  a  mixture  of  white  arsenic,  caustic  potash  and 
flowers  of  sulphur  largely  used  as  a  sheep  dip.  As  to  the  action  of  these  the 
reader  is  referred  to  the  chapter  on  "Arsenic  Poisoning." 

Dusts  of  a  hygroscopic  nature  also  are  known  to  cause  inflammation  of 
the  nasal  mucous  membrane  accompanied  not  infrequently  by  perforation  of 
the  septum.  Examples  of  this  are  sodium  chloride  (common  salt)  and  the 
chlorides  of  calcium  and  magnesium.  Among  165  persons  employed  in 
salt  grinding  and  packing,  Miiller  found  45  suffering  from  catarrh  of  the 
mucous  membrane  and  42  with  perforation  of  the  septum.  Cement  dust 
similarly  seems  to  exert  nearly  all  its  effect  on  the  upper  air  passages  (causing 
occasionally  perforation  of  the  septum),  leaving  the  lung  tissue  practically 
unaffected. 

Any  general  consideration  of  the  action  of  dust  on  the  upper  air  passages, 
however,  must  take  account  not  only  of  the  chemical  composition  but  also 
of  quantity,  quality  (whether  organic  or  inorganic  and,  if  the  latter,  whether 
metallic  or  non-metallic),  and  size  and  shape  of  the  particles.  The  effect  of 
gases  and  fumes  which  we  are  considering  in  this  relation  depends  similarly 
on  their  chemical  nature  and  on  the  concentration  in  which  they  are  present 
in  the  atmosphere  breathed. 

Dealing  first  with  dust  it  is  safe  to  say  that  no  dust,  if  inhaled  in  inordi- 
nate amount,  can  be  without  effect  on  the  mucous  membrane  of  the  upper 

296 


AFFECTIONS  OF  THE  NOSE,  MOUTH  AND  THROAT        297 

air  passages.  And  by  inhalation  in  inordinate  amount  is  meant  dust  which 
can  be  seen  constantly  rising  to  the  face  of  the  operative  in  any  manufactur- 
ing process.  The  effect  of  such  inhalation  is  to  produce  a  hyperaemia  of  the 
blood-vessels  and  frequently  an  eczematous  condition  round  the  alae  nasi, 
and  to  keep  up  a  constant  irritation  of  the  mucous  membrane  lining  the  nasal 
passages,  which  leads  first  to  hypertrophy  with  discharge  of  mucus  (the 
signs  of  chronic  nasal  catarrh)  and  passes  on  eventually,  in  the  course  of 
years,  to  atrophy  showing  itself  in  pallor  of  the  mucous  membrane  and  loss  of 
vibrissae.  The  subject  becomes  a  mouth  breather.  These  evidences  I  have 
invariably  noticed  in  workers  wherever  the  air  has  been  charged  with  fluff 
or  dust,  as  in  such  occupations  as  fur  pulling,  cotton- waste  sorting,  flannelette 
raising,  and  all  kinds  of  polishing  operations  on  a  wheel.  The  harder  and 
more  gritty  the  particles  of  dust  produced  are,  as  in  metal  grinding,  sandstone 
cutting  and  the  like,  the  more  rapidly  and  surely  will  the  condition  described 
be  produced.  My  colleague,  Dr.  ColHs,  after  examining  thousands  of  grinders 
and  granite  cutters  and  others  exposed  to  inhalation  of  dust  in  Shefl&eld, 
Aberdeen  and  elsewhere,  found,  as  a  rule,  that  the  lining  membrane  of  the 
interior  of  the  nose  for  a  distance  of  ^4  in.  was  smooth,  dry  and  pale  colored; 
the  mucous  membrane  behind  this  was  red  and  inflamed  and  generally  covered 
with  dust,  while  the  back  of  the  pharynx  and  the  pillars  of  the  fauces  were 
tolerant  of  the  touch  of  the  spatula  used  to  depress  the*  tongue,  having 
lost  their  sensitiveness. 

The  action  of  ordinary  dust,  therefore,  on  the  upper  air  passages  is  a 
mechanical  one.  Repeated  irritation  and  pressure  caused  by  deposit  of  dust 
on  the  septum  may  lead  to  ulceration  passing  on  to  a  small  perforation.  Such 
perforation — very  different  from  that  set  up  by  arsenic  and  bichromates — I 
have  observed  in  metal  grinding  and  cotton-waste  sorting.  Associated  with 
this  mechanical  irritation  arises  not  infrequently,  by  extension  along  the 
Eustachian  tubes,  inflammation  of  the  middle  ear  resulting  in  partial  deaf- 
ness. The  inflammatory  process  in  the  nose  is  continued  down  into  the 
pharynx,  eventually  leading  to  atrophy  of  the  mucous  membrane  as  a  result 
of  the  chronic  pharyngitis  set  up. 

The  distinction  between  the  effect  of  dust  upon  the  upper  air  passages 
and  upon  the  lungs  is  a  narrow  one.  It  would  be  out  of  place,  however,  to 
deal  here  with  asthmatic,  bronchitic  and  fibroid  affections  of  the  lungs,  except 
to  say  that  the  researches  of  Dr.  Collis  bring  out  the  fact  that  dusts  of  vege- 
table tissue,  especially  such  fine  dust  as  is  given  off  in  cleaning  cotton-carding 
machines  ("card  stripping")  and  in  the  early  processes  of  heckling  and 
carding  flax,  hemp  and  jute,  give  rise  to  chest  affections  which  may  be 
described  as  asthmatic,  while  inhalation  of  mineral  dusts  containing  free 
silica  gives  rise  to  fibroid  phthisis  in  proportion  as  the  free  silica  in  the  dust 
increases  in  amount.  Animal  dusts  appear  to  have  less  injurious  action  than 
either  vegetable  or  mineral  dusts. 

As  to  the  mucous  membrane  of  the  mouth,  mention  only  need  be  made  of 


298  OCCUPATIONAL   AFFECTIONS    OF   THE   NOSE,    MOUTH,    ETC. 

the  blue  line  on  the  gums  caused  by  absorption  of  lead  sulphide,  and  of  the 
intense  inflammations  set  up  by  inhalation  of  mercury  vapor  or  dust  and 
of  fumes  of  white  phosphorus,  as  they  are  all  dealt  with  at  length  in  special 
chapters.  Inhalation  of  lime  dust  in  the  unloading  of  such  cargoes  as  calcined 
spathic  ores,  in  addition  to  severe  inflammation  of  the  nose,  gives  rise  to 
development  of  small  ulcers  in  the  mucous  membrane  lining  the  buccal 
cavity. 

Mention  also  need  only  be  made  of  the  extremely  irritating  effect  on  the 
mucous  membrane  of  the  respiratory  tract  of  gases  such  as  chlorine,  sulphur 
dioxide  and  ammonia,  and  of  vapors  such  as  are  given  off  from  hydrochloric, 
sulphuric  and  nitric  acid.  Chlorine  gas  in  the  air  breathed  to  an  extent  of 
only  o.ooi  per  cent,  is  highly  injurious  to  man,  causing  cough,  dyspnoea, 
bronchial  catarrh  and,  if  excessive  quantities  are  breathed,  great  respiratory 
distress  and  rapid  death.  Hydrochloric  acid  fumes,  on  the  other  hand,  in  the 
proportion  mentioned  are  much  less  irritant.  When  the  proportion  reaches 
0.005,  toleration  becomes  difficult.  Nitrous  fumes  are  a  grave  source  of 
poisoning — if  such  a  term  can  be  correctly  applied  to  a  gas  setting  up,  when 
inhaled  in  concentrated  form,  inflammation  of  the  lungs  with  all  its  accom- 
panying symptoms  of  respiratory  distress.  Onset  of  the  acute  symptoms  is 
often  delayed  for  from  1 2  to  24  hours  after  inhalation  of  the  fumes,  the  work- 
man meanwhile  being  able  to  continue  at  his  work.  The  explanation  of  this 
is  that  time  is  needed  for  the  inflammation  to  bring  about  the  exudation  into 
the  smaller  bronchial  tubes  and  air  vesicles  which  may  eventually  completely 
fill  them. 

Hydrofluoric  acid  causes,  even  in  weak  solutions  (0.02  per  cent.),  irritant, 
symptoms  of  catarrh  of  the  mucous  membrane  of  the  respiratory  tract, 
lachrymation,  etc.  Strong  solutions  set  up  obstinate  ulcers,  difficult  to  heal, 
in  the  mucous  membrane  and  skin. 

In  considering  preventive  measures  against  inhalation  of  dust,  precedence 
must  be  given  to  its  removal  by  locally  applied  exhaust  ventilation  as,  un- 
fortunately, the  wearing  of  a  respirator  is  neither  in  itself  a  sufl&cient  protec- 
tion nor,  if  it  were,  could  the  constant  wearing  of  one  be  enforced.  The  con- 
ditions which  a  respirator  should  fulfil  to  be  effective  are,  first,  that  the  air 
breathed  is  freed  from  dust  and,  secondly,  that  it  should  not  give  discomfort  to 
the  worker.  Further,  it  should  be  simple  in  construction,  easily  applied,  and 
allow  of  frequent  cleansing  or  renewal  of  the  filtering  material.  As  a  matter 
of  fact  the  more  closely  to  the  face  a  respirator  is  made  to  fit,  and  the  more 
effectually  it  filters  the  air  breathed,  the  greater  is  the  inconvenience  experi- 
enced when  it  is  worn.  This  is  shown  in  increase  of  the  respiratory  move- 
ments and  pulse  rate  brought  about  by  the  exertion  involved  in  aspirating 
the  air  through  the  filtering  medium,  and  unavoidable  rebreathing  of  some 
of  the  expired  breath.  Respirators,  therefore,  except  for  work  lasting  a  short 
time — half  an  hour  to  an  hour — cannot  be  considered  a  sufficient  means  of 
protecting  the  worker  against  dust. 


AFFECTIONS    OF    THE   NOSE,    MOUTH   AND    THROAT  299 

II.  Chrome  Compounds  and  Their  Effects 

Chromic  acid  and  the  bichromates  of  potassium  and  sodium  are  used  in  a 
number  of  important  industries  and  may  cause  pecuHar  lesions,  namely; 
erosion  of  the  septum  of  the  nose  from  inhalation  of  the  dust,  and  ecze- 
matous  eruptions  or  ulceration  of  the  skin  when  abrasions  allow  either  the 
crystals  or  solutions  containing  them  to  penetrate  below  the  epidermal  layers 
of  the  skin. 

Manvifacture. — Potassium  bichromate  is  made  on  the  large  scale  by  roast- 
ing a  mixture  of  chrome  ironstone,  potash  and  lime,  lixiviating  the  fused  mass 
with  water,  and  adding  enough  sulphuric  acid  to  convert  the  neutral  chromate 
into  bichromate.  The  crystals  form  beautiful  adherent  masses  on  the  sides 
and  floor  of  the  crystallizing  vats.  They  are  broken  up  by  a  pick,  removed 
on  barrows  to  be  washed,  dried  in  open  stoves  by  hot  air  or  steam  pipes,  and 
finally  packed  in  barrels.  Sodium  bichromate  is  made  in  practically  the  same 
way,  sodium  carbonate  taking  naturally  the  place  of  potassium  carbonate. 
In  the  packing  of  the  sodium  compound  there  is  little  or  no  dust  owing  to  the 
hygroscopic  nature  of  the  salt,  whereas  with  the  potassium  compound  elabo- 
rate exhaust  ventilation  is  necessary  to  prevent  its  dissemination  into  the  air. 

Uses. — The  bichromates  are  much  more  used  in  the  arts  than  the  chro- 
mates  since  they  are  the  richer  in  chromic  acid.     Their  principal  uses  are: 

1.  In  the  manufacture  of  the  well-known  chrome  yellows,  oranges  and 
reds,  by  interaction  of  a  solution  of  lead  acetate  and  a  bichromate;  the  chrome 
yellows  by  mixture  with  Prussian  blue  yield  the  greens  called  "Brunswick" 
greens.  In  their  manufacture  in  addition  to  the  risk  from  chrome  there  is  the 
still  greater  one  of  lead  poisoning. 

2.  In  dyeing  and  calico  printing.  In  dyeing  cotton  yarn  an  orange  color 
the  hanks  are  first  soaked  in  limewater  and  transferred,  after  wringing,  to  a 
vessel  containing  lead  acetate.  They  then  pass  through  a  dilute  solution  of  a 
bichromate  which  develops  the  yellow  color  on  the  fiber.  Treatment  differs 
according  to  the  particular  shade  of  yellow  color  desired.  Danger  of  lead 
poisoning  has  to  be  carefully  guarded  against  from  the  dust  given  off  in  the 
"heading"  or  shaking  of  the  dried  hanks  over  a  post,  which  can  be  secured 
only  by  exhaust  ventilation  carefully  applied  to  the  heading  post. 

In  caUco  printing  potassium  bichromate  is  used  in  the  discharge  style  for 
indigo  blue  and  Turkey  red,  when  it  may  be  printed  from  a  paste  containing 
40  per  cent,  of  bichromate  which  will  discharge  the  color  from  the  blue  or 
red  material  after  suitable  treatment.  Or  it  may  be  used  for  the  production 
of  chrome  lead  colors  by  first  printing  the  desired  pattern  on  the  calico  with  a 
paste  containing  acetate  of  lead,  and  subsequently  passing  this  through  a  2 
to  5  per  cent,  solution  of  bichromate. 

In  aniline  black  dyeing  similarly,  after  treatment  with  aniline  hydro- 
chloride, the  calico  cloth  is  passed  through  a  bath  containing  dilute  solu- 
tion of  bichromate. 


300    OCCUPATIONAL  AFFECTIONS  OF  THE  NOSE,  MOUTH,  ETC. 

3.  In  photography  and  htho-etching.  The  carbon  process  depends  on  the 
fact  that  gelatine  and  potassium  bichromate  combine  under  the  influence  of 
light  to  form  an  insoluble  compound.  Thus  the  gelatine  under  the  transpar- 
ent portions  of  a  negative  when  exposed  to  light  becomes  insoluble,  retaining 
the  pigment,  while  the  darker  parts  are  unacted  upon  and  may  be  dissolved 
in  warm  water. 

4.  As  an  oxidizing  agent  for  the  manufacture  of  coal-tar  colors,  especially 
of  anthracene  to  alizarin,  and,  in  solution  with  sulphuric  acid,  as  a  bleaching 
agent  for  oil,  tallow,  etc. 

5.  In  tanning  leather  by  the  "two-bath"  process.  This  process  which  in 
the  last  15  years  has  come  into  wide  use  requires  special  mention  as  it  is  a 
frequent  cause  of  chrome  ulceration.  In  the  "one-bath"  process  basic 
chrome  salts  are  used — chrome  alum,  etc. — which  do  not  affect  the  skin. 
The  "two-bath"  process  involves  treatment  of  hides  or  skins  in  two  distinct 
solutions  generally  known  as  "chromic  acid  bath"  and  "hypo"  bath.  The 
skins  are  first  treated  with  a  solution  of  chromic  acid  made  by  the  action  of 
hydrochloric  acid  on  potassium  bichromate  (sometimes  4  per  cent,  bichro- 
mate and  4  per  cent,  acid  on  the  weight  of  the  pelt  is  used)  and  afterward  with 
a  solution  of  slightly  acidified  sodium  thiosulphate  to  reduce  the  chromic 
acid  to  a  basic  chromic  salt  which  produces  the  tannage.  Risk  of  chrome 
ulceration  is  greatest  in  the  operation  of  removing  the  skins  from  the  first 
bath,  spreading  them  out  on  a  wooden  horse  to  drain,  and  subsequently 
striking  out  the  excess  liquor — usually  by  machines  carrying  the  skin  upward 
between  rolls,  but  sometimes  by  hand  on  sloping  tables.  H.  G.  Bennett  in 
his  book  on  "The  Manufacture  of  Leather"  says:  "Equally  good  leather  is 
produced  by  the  "two-bath"  and  "one-bath"  processes,  but  the  latter  is  the 
cheaper  process  and  is  usually  more  convenient  to  manipulate.  It  has  also 
the  advantage  that  it  does  not  give  rise  to  the  painful  chrome  sores  which 
are  very  liable  to  occur  with  those  who  work  in  chromic  acid  liquors.  The 
"two-bath"  process  is  usually  considered  to  give  a  more  mellow  tannage  and 
a  better  color  than  the  "  one  bath. "...  Broadly  speaking,  it  is  more  suit- 
able for  the  lighter  leathers."  The  advantages  of  chrome  tanning  seem  to 
lie  in  the  quickness  of  the  process  so  that  the  tanner  has  a  larger  turnover 
than  with  vegetable  tanning.  Hyposulphite  of  soda  is  recognized  as  useful 
in  the  treatment  of  chrome  sores  and  use  can  be  made  of  this  fact  by  trans- 
ference to  work  on  the  "hypo"  bath  of  those  suffering  from  chrome  holes. 

6.  In  French  poHshing,  especially  for  darkening  mahogany  and  walnut 
wood,  the  grain  of  which  is  brought  out  more  clearly  by  bichromate  than  by 
any  other  substance.  The  hquid  is  applied  generally  with  a  cloth — more 
rarely  with  a  brush. 

7.  As  an  ingredient  of  safety  matches  and  in  the  preparation  of  colored 
glass  and  porcelain. 

Effect  on  the  Skin.^ — There  is  consensus  of  medical  opinion  that  bichro- 
mate solutions  do  not  attack  the  unbroken  skin.     The  slightest  break  in 


AFFECTIONS    OF    THE    NOSE,    MOUTH    AND    THROAT  3OI 

continuity,  however,  especially  where  this  is  thin,  as  over  the  knuckles  or 
between  the  fingers,  suflQces  to  start  the  destructive  process  which,  once  it  has 
begun,  will  penetrate  gradually  through  the  soft  tissues  unless  means  are 
taken  to  prevent  further  contact  with  the  solution.  The  seat  of  election  for 
these  sluggish  ulcers  or  "chrome  holes,"  as  they  are  called  by  the  workmen, 
is  either  on  the  knuckles  or  at  the  root  of  the  nail,  but  they  may  occur  on 
any  part  of  the  hands,  forearm  or  foot.  Where  contact  has  been  with  dust 
I  have  seen  them  on  the  neck  and  in  the  groin.  The  tissues  around  the  cir- 
cular ulcer  are  heaped  up,  thickened,  indurated  and  always  undermined; 
the  center  is  filled  by  a  slough.  When  the  slough  has  been  removed  the  floor 
of  the  ulcer  is  seen  to  consist  of  grayish-yellow  granulation  tissue.  In  the 
majority  of  cases  the  diameter  of  the  ulcer  is  not  more  than  ig  in.,  in  diameter, 
in  a  few  it  is  3^^  in.  and  the  largest  I  have  seen  measured  ^4  by  3-^  in.  The 
number  of  active  chrome  holes  to  be  found  on  the  hands  of  some  workers  when 
supervision  is  lax  is  surprising.  In  one  man  employed  as  a  breaker  in  the 
crystal  department  of  a  bichromate  works  I  found  four  on  the  right  forearm, 
ten  on  the  left,  two  in  the  groin  and  one  on  the  back  of  the  neck.  In  another 
man,  similarly  employed,  chrome  holes  were  found  at  the  matrix  of  the  nail 
of  the  index-finger  of  the  right  hand,  and  ring  and  little  fingers  of  the  left 
hand;  the  index-finger  was  much  swollen  and  inflamed;  on  other  parts  of  the 
hands  also  chrome  holes  were  numerous.  It  is  unusual  not  to  be  able  to  find 
small  ulcers  or  the  scars  of  ulcers  that  have  healed  on  the  hands  of  those 
employed  in  chrome  tanning  and  in  dyeing.  Fortunately,  to-day,  penetra- 
tion into  joints  and  loss  of  fingers,  described  by  early  writers  on  the  subject, 
are  very  rarely  seen.  Sometimes  instead  of  taking  the  form  described  of 
localized  ulcers,  chromic  acid  in  solution,  as  in  the  "two-bath"  tanning  proc- 
ess, sets  up,  in  susceptible  subjects,  an  extensive  papular  eruption  on  the- 
hands  and  forearms,  and  occasionally  on  the  feet  and  ankles  also,  accompanied 
by  intense  itching.  In  slub  dyeing  the  chrome  affection  is  found  usually 
around  the  knuckles,  on  the  palm,  in  the  fold  between  the  thumb  and  first 
finger,  and  about  the  wrist  and  forearms.  The  eczematous  condition  may 
extend  to  other  parts  of  the  body  such  as  the  face  and  back.  Susceptibility 
plays  an  important  part  in  disease  of  an  eczematous  nature  the  skin  of  some 
persons  reacting  much  more  readily  to  definite  known  irritants  such  as 
chromic  acid  than  that  of  others.  Experience  can  alone  decide  whether  a 
particular  person  will  be  able  to  continue  at  the  work  or  not. 

Where  the  ulcerative  process  is  serious  it  is  impossible  not  to  be  struck 
either  by  peculiar  susceptibility  of  the  skin  or  by  the  evident  want  of  care  or 
ignorance  on  the  part  of  the  sufferers.  New  workers  suffer  much  more  than 
the  seasoned  who  have  experienced  the  painful  condition.  Lads  of  14  and  15 
years  of  age  who  start  work  in  chrome  tanning  are  sure  to  suffer  if  super- 
vision is  lax.  The  amount  of  pain  and  inconvenience  caused  by  chrome 
holes  is  considerable.  They  are  never  a  menace  to  life,  but  I  have  known 
six  men  absent  in  i  year  from  one  establishment  for  periods  varying  from  3 


302  OCCUPATIONAL   AFFECTIONS    OF   THE    NOSE,    MOUTH,    ETC. 

to  9  weeks  on  account  of  them.     Even  when  the  severity  is  not  such  as  to 
necessitate  absence  from  work,  months  may  elapse  before  they  heal. 

My  experience  dates  back  to  the  year  1899  when  in  consequence  of  the 
prevalence  of  chrome  ulceration  in  the  large  bichromate  works  in  Scotland 
employing  743  men,  of  whon  306  were  engaged  in  processes  involving  ex- 
posure to  chrome,  I  visited  the  factories  and  examined  the  workmen,  taking 
note  in  each  case  of  the  age,  duration  of  employment,  precise  occupation, 
condition  of  the  septum  after  examination  with  the  nasal  speculum,  sense 
of  smell  after  testing  with  the  essential  oils  of  cloves  and  camphor,  condition 
of  the  throat  and  eyes,  and  existence  or  absence  of  present  or  past  chrome 
ulceration.  In  39  out  of  the  176  men  (22.1  per  cent.)  examined,  one  or  more 
unhealed  ulcers  were  found  and  in  several  others  numerous  scars  marking 
the  site  of  bygone  ulcers. 

In  126  men  (71.5  per  cent.)  the  septum  of  the  nose  was  the  site  of  per- 
foration, and  in  20  others  of  ulceration,  in  all  probability  a  stage  preceding 
perforation.  Nearly  all  the  men  employed  in  the  crystal  department  and 
at  the  furnaces  showed  perforation.  It  was  noted  as  having  taken  place  in 
one  instance  after  a  duration  of  employment  of  only  7  weeks,  and  in  two 
others  of  less  than  3  months.  Usually  it  appears  between  the  sixth  and 
twelfth  month  after  commencing  work. 

Nature  of  the  Perforation. — The  cartilaginous  framework  of  the  nose 
consists  of  five  pieces — ^the  two  upper  and  the  two  lower  lateral  cartilages, 
and  the  cartilage  of  the  septum.  The  two  upper  and  the  two  lower  lateral 
cartilages  give  the  nose  much  of  its  shape  and  form  the  alse  nasi.  The 
ulceration  process  due  to  bichromate  dust  never  attacks  them.  The  cartilage 
of  the  septum  is  somewhat  triangular  in  form  and  thicker  at  its  margins 
than  at  the  center.  The  anterior  margin,  thickest  above,  is  connected 
from  above  downward  with  the  nasal  bones,  the  front  part  of  the  two  upper 
lateral  cartilages,  and  the  inner  portion  of  the  two  lower  cartilages.  Its 
posterior  margin  is  connected  with  the  perpendicular  lamella  of  the  ethmoid; 
its  inferior  margin  with  the  vomer  and  the  palate  processes  of  the  superior 
maxillary  bones.  The  seat  of  election  for  the  perforation  to  commence  is 
a  point  about  3>^  in.  from  the  lower  and  anterior  margin  of  the  septum;  the 
ulceration  extends  in  a  direction  upward  and  backward.  This  point  is 
precisely  that  where  inhaled  dust  ahghts  and  I  have  no  doubt  dust  is  the 
cause. 

The  limitation  of  the  perforation  to  the  cartilage  of  the  septum  is  ac- 
counted for  by  the  fact  that  the  mucous  membrane  covering  it  is  adherent, 
forming  the  perichondrium,  and  is  far  less  vascular  than  the  mucous  mem- 
brane lining  the  rest  of  the  nasal  fossie.  Once  the  mucous  membrane  is 
destroyed,  the  blood  supply  to  the  cartilage  is  cut  off,  and  necrosis  ensues. 
The  ulceration  having  progressed  upward  as  far  as  the  junction  of  the  septum 
with  the  ethmoid  and  backward  to  the  vomer,  becomes  arrested.  Healing 
then  takes  place,  the  bone  never  being  attacked,  and  the  cicatrix  usually 


AFFECTIONS    OF   THE   NOSE,    MOUTH   AND    THROAT  303 

becomes  covered  with  an  echthymatous  crust  of  mucus.  In  no  instance 
was  the  anterior  of  lower  border  of  the  septum  destroyed.  Consequently 
the  rigidity  of  the  parts  is  maintained,  and  deformity,  so  prominent  in  other 
ulcerative  processes  attacking  the  nose,  is  absent. 

The  onset  of  the  morbid  process  is  ushered  in  by  sneezing  and  the  ordi- 
nary symptoms  of  nasal  catarrh.  The  pain  accompanying  the  ulceration 
appears  to  be  insignificant.  At  any  rate  it  had  never  been  severe  enough  to 
necessitate  absence  from  work  or  to  call  for  medical  treatment.  The  only 
apparent  inconvenience  which  results  is  the  formation  of  plugs  of  mucus  in 
the  nasal  passages. 

Mucous  deposits  and  white  patches  were  occasionally  noted  on  the 
pharynx,  but  definite  ulceration  was  in  no  case  detected.  Asthma,  noted  by 
the  French  writers  on  the  subject,  Delpech  and  Hillairet,  was  found  in  one 
instance — that  of  the  partner  in  one  of  the  works.  In  his  case  there  was  a 
family  predisposition  to  it,  but  the  first  definite  attack  dated  from  contact 
with  bichromate  dust. 

Preventive  and  Remedial  Measures. — In  factories  for  the  manufacture 
of  bichromates  Regulations  are  necessary,  prescribing  as  their  main  provision 
periodical  medical  examination  of  the  workers  and  treatment  by  the 
appointed  surgeon  of  lesions  contracted  in  the  work.  In  addition,  it  is 
essential  that  some  responsible  person  with  knowledge  of  first  aid  should 
be  appointed  to  treat  daily  such  cuts  and  abrasions  as  occur.  One  of  the 
surgeons  carrying  out  this  work  writes  to  me  as  follows: 

As  chrome  holes  are  usually  produced  from  trifling  or  unseen  abrasions  about  the  hands  I 
insist  upon  the  foreman  examining  the  hands  of  the  men  daily  in  order  to  see  if  there  is  any 
irritation  of  the  skin  and,  if  found,  to  have  the  parts  thoroughly  washed  and  afterward  pro- 
tected by  dressings.  This  recommendation,  I  consider,  is  important  in  that  it  impresses 
on  the  men  the  benefit  of  checking  at  once  tendency  to  the  development  of  chrome  holes. 
They  can  be  developed  in  a  day  although  the  escharotic  effect  of  the  chrome  may  not  be 
apparent  for  a  day  or  two  afterwards. 

In  order  to  seal  up  a  chrome  hole  and  prevent  further  contact  with  the  liquor  I  use  an 
ointment  of  zinc  or  borax  on  a  small  piece  of  lint  to  cover  the  hole.  I  cover  the  lint  with 
gutta-percha  tissue  the  edges  of  which  I  soften  with  heat  from  a  taper  or  chloroform  and  then 
squeeze  close  to  the  skin.  Adhesive  plaster  may  also  be  used  as  a  further  protection  over 
the  gutta-percha  tissue.  Attention  must  be  paid  to  see  that  the  men  are  following  out  the 
treatment  and  that  the  sores  are  improving — otherwise  there  is  no  alternative  but  to  remove 
the  man  from  the  chrome  department  until  the  wounds  are  healed. 

Another  surgeon  after  insistence  on  the  importance  of  covering  up  the 
smallest  scratches  thus  describes  his  treatment  of  chrome  sores : 

I  apply  poultices  by  night  to  clean  off  the  gra}'  slough,  and  to  diminish  the  inflammation 
of  the  thickened  edges.  In  addition,  I  endeavor  by  scraping  to  remove  the  gray  slough  from 
the  floor  and  scrape  also  underneath  the  undermined  edges.  I  pack  the  little  hole  with 
boracic  lint  or  preferably  with  cyanide  gauze,  and  so  further  stimulate  and  encourage 
healing.  Healing,  however,  is  a  slow  process  and  it  is  a  very  small  hole  which  heals  in  less 
than  3  months. 


304  OCCUPATIONAL    AFFECTIONS    OF    THE    NOSE,    MOUTH,    ETC. 

Instead  of  the  poulticing  other  surgeons  use  boracic  fomentations  and  apply 
yellow  ointment  of  mercury,  or  clean  with  hydrogen  peroxide  solution  and 
treat  with  an  ointment  containing  ichthyol  applied  under  an  absolutely 
waterproof  plaster.  Washing  with  a  5  per  cent,  solution  of  sodium  bisul- 
phite has  been  recommended  on  the  ground  that  by  its  means  the  chromic 
acid  radicle  is  split  up  and  rendered  inert. 

Where  the  hands  come  into  contact  with  bichromate  solutions,  as  in  chrome 
tanning  by  the  "two-bath"  process  and  in  dyeing,  the  first  essential  again  is 
daily  inspection  of  the  hands  and  arms  of  all  the  workers  and  immediate 
covering  over  of  the  smallest  abrasion  so  as  to  protect  it  against  further 
contact  with  the  solution.  For  this  purpose  collodion  ("new  skin")  is  in- 
valuable, but  if,  as  may  be  the  case  over  the  knuckles  it  is  inapplicable  a  dress- 
ing under  an  impermeable  waterproof  plaster  or  closely  fitting  India-rubber 
fingerstall  must  be  used  instead.  In  chrome  tanning  India-rubber  gloves 
reaching  well  up  toward  the  elbow  are  a  great  protection,  but  the  wearing  of 
them  does  not  make  the  treatment  of  abrasions  unnecessary.  I  have  found 
them  generally  provided  and  worn,  but  the  retention  of  perspiration  caused 
by  their  use  may  tend  to  soften  the  skin  in  some  cases.  Only  where  disci- 
pline and  supervision  are  thorough  would  it  be  safe  to  throw  aside  the  pro- 
tection of  India-rubber  gloves.  Substitutes  for  them  such  as  leather  gloves 
are  in  my  experience  wholly  unsatisfactory.  Periodic  medical  examination 
of  persons  employed  in  chrome  tanning  is  useful  as  it  ensures  choice  of 
proper  dressings,  is  a  check  on  the  way  in  which  the  foreman  exercises 
supervision,  and  will  prevent  chrome  holes  from  causing  prolonged  absenta- 
tion from  work. 

Lastly,  smearing  of  the  arms  and  hands  with  fat  or  with  special  ointments 
undoubtedly  serves  as  a  protection  to  the  skin.  The  following  is  the  prepa- 
ration recommended  by  Levi,  Chemist  of  the  Pfister  and  Vogel  Leather 
Company,  Milwaukee: 

Petrolatum  (Paraffinum  moUe  of  the  B.  P.) 3  parts 

Lanoline .  .  .  i  part 

Melt  on  the  water  bath  or  stove;  when  melted  and  thoroughly  mixed,  add 
10  to  15  drops  of  90  per  cent,  pure  carbolic  acid  to  every  400  grams,  or  5  drops 
to  every  4  oz.  of  the  mixture.  Pour  into  a  glass  or  earthenware  jar  and  allow 
the  mass  to  solidify,  when  it  is  ready  for  use. 

The  application  is  as  follows:  Let  the  workman  clean  his  hands  and  arms 
thoroughly  with  soap  and  water.  Rinse  with  warm  water  and  while  still 
moist  apply  the  ointment.  Rub  in  well,  so  as  to  cover  all  exposed  skin,  for 
about  2  to  3  minutes.  Then  take  a  clean  cloth  and  wipe  dry.  The  skin  will 
be  left  entirely  dry  and  with  no  greasy  feeUng.  LanoHne  is  absorbed  by  the 
skin  and  the  petrolatum  forms  a  light  coating  on  the  surface.  The  applica- 
tion of  the  two  inert  substances  prevents  the  action  of  the  chrome  upon  the 


AFFECTIONS    OF    THE    NOSE,    MOUTH    AND    THROAT  305 

surface  and  at  the  same  time  the  absorbed  grease  prevents  the  action  of  the 
chrome,  should  the  outer  coating  of  petrolatum  wear  off. 

My  colleague  Dr.  Collis,  struck  by  the  remark  of  a  chrome  tanner  that  a 
dilute  solution  of  mercuric  chloride  or  solution  of  cyllin  when  used  as  a  hand 
bath  prevented  the  development  of  ulcers,  possibly  because  the  ulcer  forma- 
tion was  due  to  microbic  action,  supervening  on  the  action  of  the  bichromate, 
has  had  trial  given  with  fair  success  to  an  ointment  composed  of  mineral 
lard  3  lb.,  paraffine  wax  6  oz.,  and  cyllin  3  oz.  Mineral  lard  is  used  instead 
of  lanoline  to  prevent  oxidation  by  the  chromic  acid. 

In  a  case  of  severe  papular  eczema  arising  from  contact  with  ammonium 
bichromate  used  in  photo-engraving  application  of  equal  parts  of  calamine 
and  boracic  acid  lotions  quickly  proved  efficacious.  These  are  the  cases, 
however,  which  are  liable  to  relapse  on  fresh  exposure  and  raise  the  question 
as  to  further  continuance  in  the  process. 

The  effect  of  chrome  dust  on  the  nasal  septum,  despite  elaborate  exhaust 
ventilation  applied  in  packing  the  crystals,  cannot  wholly  be  avoided.  The 
inconvenience  caused  by  its  occurrence  is  not  sufficiently  great  apparently 
to  induce  the  workmen  to  adopt  precautions  which  might,  if  regularly  used, 
be  effective,  such  as,  cotton  wool  plugs  or  smearing  the  septum  with  paraffine. 
The  surest  preventive  measure  is  effort  directed  to  reduce  to  a  minimum 
generation  of  dust.  Fischer  states  that  daily  use  of  an  ointment  composed 
of  50  grams  zinc  oxide,  22  grams  olive  oil,  18  grams  liquefied  ichthyol,  and 
10  grams  balsam  of  Peru  has  caused  the  disappearance  in  from  3  to  4  weeks  of 
signs  of  ulceration  on  the  septum  in  those  commencing  work. 

The  Regulations  in  force  in  bichromate  works  in  Great  Britain  emphasize 
the  need  for  fencing  of  uncovered  vats,  and  provision  of  meal  room,  cloak 
room,  washing  and  bath  accommodation,  in  addition  to  exhaust  ventilation 
and  periodic  medical  examination. 

I  agree  with  the  conclusion  of  Fischer  and  Lehmann,  who  have  recently 
carefully  examined  the  conditions  in  the  bichromate  works  in  Germany  (the 
latter  having  also  carried  out  animal  experiments  as  to  the  effects  of  chrome 
compounds),  that  no  constitutional  disease,  and  especially  no  disease  of  the 
kidneys,  is  induced  by  work  in  bichromate  factories  or  in  chrome  tanning. 

Manufacture  of  chromates  of  lead  is  attended  with  considerable  risk 
of  lead  poisoning.  Lighter  shades  are  made  by  a  cold  precipitation  process 
and  the  deeper  shades  of  orange  and  red  by  boiling  the  ingredients — lead 
acetate,  pulp  white  lead,  bichromate  of  potash  and  soda  and  sulphate  of 
soda — while  barytes  is  added  as  the  color  is  being  made.  Danger  in  the  first 
method  hardly  arises  until  drying  and  grinding  under  edge  runners,  sieving 
and  packing,  are  effected.  The  dust,  when  inhaled,  is  quickly  absorbed,  and 
carefully  arranged,  exhaust  ventilation  is  necessary  in  all  operations  in  which 
dust  is  generated.  Vessels  in  which  boiling  is  effected  require  to  be  hooded 
over  and  the  hood  connected  up  with  an  efficient  exhaust  draught.  Grinding 
of  chrome  greens  is  a  very  dusty  process  and,  although  only  10  per  cent,  of 


3o6         OCCUPATIONAL  AFFECTIONS   OF   THE   NOSE,   MOUTH,    ETC. 

lead  may  be  present,  poisoning  will  occur  in  the  absence  of  encasing  and 
exhaust  ventilation.  In  an  analysis  of  225  cases  of  lead  poisoning  distributed 
according  to  precise  occupation  I  found  at  least  10  per  cent,  were  traceable 
to  chrome  colors. 

Cotton  yarn  is  dyed  on  a  considerable  scale  with  chromate  of  lead.  Much 
of  the  yarn  so  dyed  goes  to  Oriental  markets  and  it  is  the  orange  chrome — 
that  most  heavily  weighted  with  lead — which  is  most  in  demand  there.  Not 
a  few^outbreaks  of  severe  lead  poisoning  have  occurred  among  the  workers — 
generally  women — engaged  in  shaking  out  the  yarn  over  heading  posts — 
due,  in  every  case,  to  a  breakdown  in  the  exhaust  ventilation  locally  apphed. 

In  both  the  manufacture  of  paints  and  colors  and  heading  of  yarn  dyed 
with  lead  compounds,  Regulations  are  in  force  in  Great  Britain  prescribing 
periodic  medical  examination. 

REFERENCES 

Memoire  sur  les  accidents  auxquels  sont  soumis  les  ouvriers  employes  a  la  fabrication  des 

chromates. "    Annales  d  Hygiene  publique,  1869,  page  5;  and  1876,  pages  5  and  193. 
Die  in  Chromatfabriken  beobachteten  Gesundheitsschadigungen  und  die  zur  Verhutung 

derselben  erforderlichne  Masshahmen,"  by  Drs.  Wutzdorf  and  Heise.     Arbeiten  aus 

dem  Kaiserlichem  Gesundheitsamte,  Vol.  XIII. 
Article  on  "The  Lesions  Resulting  from  the  Manufacture  and  Uses  of  Potassium  and 

Sodium  Bichromate,-'  by  T.  M.  Legge,  in  Oliver's  "Dangerous  Trades,"  page  447. 
Die  Berufskrankheiten  des  Ohres  und  der  oberen  Luftwege,"  by  Dr.  F.  Ropke,  J.  F.  Berg- 

mann,  Wiesbaden,  1902. 
Die  industrielle  Herstellung  und  Verwendung  der  Chrbmverbindungen,  die  dabei  ent- 

stehenden  Gesundheitsgefahren  fiir  die  Arbeiter  und  die  ]\Iassnahmen  zu  ihrer 

Bekampfung,"byDr.  R.  Fischer.     One  of  the  publications  of  the  Institut  fiir  Gewer- 

behygiene  of  Frankfort  a.  Main.  A.  Seydel,  Berlin,  191 1. 
"Die  Bedeutung  der  Chromate  fiir  die  Gesundheit  der  Arbeiter,"  by  Professor  K.  B.  Leh- 

mann.     One  of  the  publications  of  the  Institut  fiir  Gewerbehygiene  of  Frankfurt, 

Julius  Springer,  Berlin,  1914.  Die  Zeitschrift  fiir  Gewergehygiene,  1908,  page  307. 
Annual  Reports  of  the  Chief  Inspector  of  Factories  for  1899,  page  334,  and  1914,  pages 

146  and  147. 
"The  Eflfects  of  Dust  in  Producing  Diseases  of  the  Lungs,"  by  E.  L.  Pollis,  M.  B.,  17th 

International  Congress  of  Medicine,  London,  1913. 


CHAPTER  II 
A.  OCCUPATIONAL  INJURIES  AND  DISEASES  OF  THE  EYE 

BY  H.  V.  WtJRDEMANN,  M.  D.,  Seattle,  Washington. 

Certain  industrial  occupations  involve  particular  risk  to  the  eyes  from 
acquired  disease  and  intoxication  or  by  reason  of  accidents.  It  may  be  said 
that  each  trade  has  its  own  eye  diseases  and  particular  forms  of  trauma,  and 
in  some  the  relation  of  the  ocular  damages  to  the  risk  encountered  is  very 
great  indeed. 

The  employer  has  now  to  take  into  consideration  not  only  the  medical 
care  and  hospital  service  for  injured  employees  and  compensation  of  dam- 
ages therefor,  but  in  many  states  and  countries  is  compelled  by  law  as  well 
as  sentiment  to  put  in  safety  appliances  which  have  come  to  be  known  as 
money-saving  propositions,  as  well  as  reducing  the  number  of  workmen 
laid  up  by  reason  of  accident  and  disease. 

The  intelligent  workman  does  not  desire  plenary  damages,  for  health  as 
well  as  sight  is  priceless,  but  he  does  now  insist  upon  his  work  being  made  as 
safe  and  free  from  accident  and  disease  as  possible. 

A  very  large  proportion  of  the  injuries  occurring  in  trades  happen  to  the 
eyes,  probably  as  many  in  number  as  all  other  injuries,  and  as  a  workman 
needs  good  eyesight  he  is  usually  totally  incapacitated  by  such  a  lesion. 

The  subjects  to  be  considered  may  be  arranged  as  follows,  in  which 
discussion  I  will  deal  mostly  with  the  etiology  and  prevention  of  such 
incapacitations:  i 

I.  Injuries  from  accidents. 

II.  Diseases  due  to  occupations,  involving  excessive  eye  strain. 
HI.  Diseases  due  to  excessive  exposure  to  light  and  heat. 

IV.  Toxicology  or  systemic  poisoning  causing  loss  of  sight. 

V.  The  estimation  of  economic  damage. 

I.  ACCIDENTAL  INJURIES 

By  far  the  larger  proportion  of  these  happen  in  the  iron  and  steel  trades 
where  the  workman  is  exposed  to  cuts,  burns,  bruises  and  flying  foreign  bodies. 
Indeed  in  shops,  such  as  wire,  chain,  tool  and  machinery,  as  many  accidents  to 
the  eye  may  occur  in  a  year  as  there  are  workmen  employed.  Most  of  them 
are  trivial  injuries  such  as  motes  in  the  eye,  laying  the  man  up  but  for  an  hour 
or  a  day  or  two;  others  however,  expose  him  to  partial  or  complete  loss  of 

307 


3o8  OCCUPATIONAL   AFFECTIONS    OF   THE    NOSE,    MOUTH,    ETC. 

eyesight  with  total  loss  of  earning  power  immediately  following  the  accident 
or^occurring  months  or  even  years  afterward,  as  from  sympathetic  disease. 
The  cosmetic  relations  of  these  eye  injuries  are  important,  for  a  one-eyed 
man  finds  it  difficult  to  obtain  a  job.  A  white  scar  on  the  cornea,  or  a  squint, 
even  though  little  or  not  at  all  affecting  the  vision  may  be  the  deciding  power 
in  rejecting  a  man  who  otherwise  is  well  qualified. 

ETIOLOGY  OF  INDUSTRIAL  INJURIES 

In  the  so-called  dangerous  trades,  particularly  those  dealing  with  the 
iron  and  steel  industries,  workers  in  machinery,  butchering  work,  and  building 
trades,  occur  the  larger  number  of  ocular  injuries.  Among  these  are  the 
miners  of  iron,  copper  and  coal,  the  smelters  and  machine  builders.  Those 
that  are  most  subject  to  flying  foreign  bodies  causing  wounds  of  the  eye  are 
foundrymen,  machinists,  turners,  borers,  boiler  makers,  fettlers,  smiths  and 
polishers;  workers  by  the  fire  and  heat,  puddlers,  casters,  glass  workers,  etc., 
are  burned  by  fire,  ashes  or  iron  and  slag.  Contusions  of  the  eye  from  falls, 
blows  and  thrusts  come  to  all  classes. 

In  agricultural  pursuits  there  are  many  kinds  of  injuries,,  'especially  from 
foreign  bodies.  In  lands  where  the  ground  is  tilled  largely  by  hoes,  as  in  the 
stony  country  of  Switzerland,  the  breaking  of  these  instruments  against  the 
rocks  causes  many  such  injuries. 

In  agricultural  pursuits  the  causes  are  injuries  by  straws,  by  branches  in 
the  woods,  in  working  about  cattle  and  by  farming  implements.  There  were 
injuries  from  foreign  bodies  in  the  cornea  and  conjunctiva,  perforating  wounds, 
contusions  from  sharp  or  pointed  objects,  injuries  from  lime  or  dung,  burns 
and  insect  stings.  Cauterizations  from  the  arsenate  of  lead  have  recently 
been  reported  in  spraying  orchards. 

In  the  building  trades  there  are  injuries  from  iron,  stone  particles,  and 
splinters  of  wood,  and  from  instruments  used  in  work;  in  quarries  and  mines, 
explosions  of  powder  and  dynamite.  Injuries  from  lime  are  common  among 
painters.  In  laboratory  workers,  foreign  bodies,  burns  and  scalds,  and  splint- 
ers of  glass;  in  glass  blowing,  burns  and  formation  of  cataract;  in  cabinet 
workers  injuries  from  the  materials  they  work  with,  steel,  wood  and  bone; 
in  turners,  injuries  from  wood,  bone,  ivory,  and  stone,  blows  from  sharp 
knives,  etc. 

Generally  the  injury  is  inflicted  by  fragments  flying  off  while  the  mechanic 
is  striking  a  chisel  or  piece  of  metal,  as  a  hatchet  or  hammer. 

Solids  or  gaseous  substances  may  cause  conjunctivitis  in  people  exposed 
to  the  inclemencies  of  weather,  stone  impregnation  of  the  cornea  in  stone- 
cutters, ribbon-shaped  keratitis  in  hat  makers,  masons,  steel  grinders,  opaci- 
ties of  cornea  due  to  nitronaphthahn  and  aniline,  keratitis  of  oyster  openers 
and  caisson  laborers,  cataract  of  glass  blowers.  We  may  probably  give  the 
most  prominent  place  to  grinders  or  to  workmen  in  factories  who  are  either 


OCCUPATIONAL    INJURIES    AND    DISEASES    OF    THE    EYE  309 

constantly  employed  in  grinding  edged  tools,  or,  as  is  common  in  this  dis- 
trict, care  for  their  own  tools,  and  find  occasion  to  go  to  the  grindstone  or 
emery  wheel  a  number  of  times  daily.  In  such  trades  foreign  bodies  are 
very  prone  to  become  lodged  in  the  cornea.  In  the  course  of  a  day  a  grinder 
may  get  several  foreign  bodies  in  his  cornea  or  many  days  may  elapse  without 
so  doing.  If  the  cornea  of  an  old  grinder  be  examined  carefully  with  a  mag- 
nifying glass,  it  will  be  frequently  found  studded  over  with  nebulae  caused  by 
damage  from  getting  motes  in  the  eye  which,  by  frequent  repetition,  will 
dull  the  cornea  and  after  a  while  will  diminish  the  acuteness  of  vision.  I 
have,  hovv-ever,  seen  many  workmen  with  such  scars  who  possess  normal 
visual  acuity.  These  nebulae  have  been  caused  by  small  fragments  of  emery, 
or,  more  rarely,  stone  or  pieces  of  iron.  In  localities  where  emery  is  used  for 
glazing  cutlery,  such  accidents  are  very  common.  To  those,  who  have 
watched  a  grinder  at  work  it  is  remarkable  how  any  one  can  remain  at  the 
wheel  without  getting  foreign  bodies  into  the  eye  every  few  minutes.  The 
shower  of  sparks  which  proceeds  from  the  dry  grinding  wheel  shows  the  large 
number  of  foreign  bodies  that  come  away.  Dry  grinding  is  certainly  more 
dangerous  as  regards  the  eyes  than  wet  grinding,  as  in  the  former  the  sparks 
fly  freely  and  it  is  a  chance  whether  they  hit  the  man's  eye  or  scatter  about  the 
room.  The  pneumatic  fans  which  are  required  in  many  of  the  United  States 
and  in  England,  in  consequence  of  the  deleterious  effect  of  the  dust  upon  the 
health  of  the  operators,  protect  the  workman's  eyes  by  drawing  into  them- 
selves the  sparks  and  particles  flying  from  the  wheel.  In  wet  grinding 
the  particles  do  not  fly  about  so  much;  still  the  workman's  face  becomes 
bespattered. 

In  the  great  majority  of  cases  the  damage  occasioned  by  mishaps  of  this 
character  is  not  serious  unless  ulceration  follows.  Other  accidents,  of  course, 
may  follow  upon  the  injury  to  the  eye  on  account  of  the  disabiUty  and  les- 
sened protection  that  is  thereby  produced.  In  the  case  of  workmen  who  fre- 
quently get  injuries  to  their  eyes,  and  always  where  a  workman  or  patient 
has  lost  an  eye,  I  ad\-ise  the  securing  of  an  accident  policy  on  account  of  the 
greater  danger  of  injury  from  the  lessened  functional  ability. 

By  far  the  most  serious  eye  accidents  happen  to  men  engaged  in  working 
in  iron  or  steel.  Particularly  in  iron  manufacturing  districts  the  majority 
of  serious  eye  accidents  occur  from  chipping  or  fettling  iron  and  steel,  in  the 
lighter  iron  and  steel  industries  as  well  as  in  the  heavy  trades,  where  armor 
plates  are  made  and  hea\y  castings  of  scores  of  tons.  A  very  large  propor- 
tion of  the  accidents  are  occasioned  by  what  is  called  "chipping"  and  "fet- 
thng."  "Dressing"  is  the  name  given  in  some  parts  of  this  process.  This 
work  consists  in  chipping  the  rough  edges  from  steel  and  iron  castings,  ingots, 
and  all  kinds  of  iron  and  steel  work,  and,  among  other  things,  even  large 
armor  plates. 

Castings  of  either  iron,  steel,  or  brass  are  the  most  dangerous  to  work 
upon,  because  the  chippings  fly  about  on  account  of  the  metal  being  brittle. 


3IO  OCCUPATIONAL   AFFECTIONS    OF    THE    NOSE,    MOUTH,    ETC. 

It  is  very  dangerous  to  chip  castings  in  corners  or  where  the  chipping  strikes 
the  metal  and  rebounds.  Chippings  from  the  castings  are  about  34  to  %  in. 
long  and  very  sharp.  When  thin  plates  are  chipped  on  the  edges,  the  chip- 
pings are  sometimes  i,  2,  and  3  in.  long  before  they  break  off.  All  castings 
are  fettled  at  the  foundry,  that  is,  the  runners  are  cut  off,  and  the  plates  where 
the  metal  has  run  at  the  joint  of  the  moulding  boxes  are  trimmed  off. 


Fig.  13. — Men  at  boring  mill  should  provide  themselves  with  goggles  as  at  any  time 
a  chip  is  liable  to  injure  the  eyes.     U.  S.  Steel  Corp'n.     {Wiirdemann.) 


Whatever  be  the  special  kind  of  metal  or  steel  to  be  fettled,  the  manner 
in  which  it  is  done  is  practically  the  same.  A  hammer  and  chisel  or  sate  are 
used,  and  with  these  the  roughness  is  removed.  Frequently,  also,  while  one 
man  places  the  chisel,  another,  or  even  two  others,  will  use  the  hammer  and 
are  called  strikers.  I  understand  that  at  works  where,  say,  1000  men  are 
employed,  200  or  more  will  be  occupied  more  or  less  in  chipping.  Many  men 
are  frequently  working  close  to  each  other,  so  that  the  danger  is  not  only  to 
the  worker  himself,  but  to  those  around.  Passers-by  are  by  no  means  infre- 
quently the  victims,  and  many  blinded  in  this  way  have  come  under  my 
notice.  The  chipper  himself  is  often  hit  by  the  rebound  of  the  spUnter  after 
it  has  struck  perhaps  the  narrow  angle  of  steel  or  iron  upon  which  he  may  have 


OCCUPATIONAL   INJURIES    AND   DISEASES    OF    THE    EYE  311 

been  working,  or  some  other  object.  It  must  be  recollected,  also,  that  in  the 
process  spoken  of  the  danger  is  not  merely  from  the  iron  or  steel  which  is 
being  operated  upon,  but  there  are  three  other  places  from  which  splinters 
may  be,  and  actually  are,  given  off  and  cause  injury,  namely:  the  hammer- 
head, the  chisel-head,  and  the  chisel-point. 

The  sizes  vary  from  the  most  minute  to  others  measuring  some  inches  in 
length,  and  they  may  be  thick  or  thin.  The  injury  inflicted  differs,  of  course, 
in  accordance  "udth  the  size  of  the  missile  and  the  force  with  which  it  is 
projected.  The  small  fragments  may  be  thrown  off  with  such  velocity  that 
they  penetrate  the  eyeball  and  become  imbedded  in  its  interior,  in  some  in- 
stances passing  through  the  eyehd  before  reaching  the  globe.  The  destruc- 
tion to  sight  in  this  way  is  very  large. 

In  the  case  of  breweries  and  botthng  works,  particularly  of  botthng  of 
aerated  water,  there  is  a  comparative  frequency  of  accidents  from  the  break- 
ing of  the  containers.  A  firm  in  Sheffield  having  several  different  factories 
employing  from  2500  to  4200  hands  states  that  in  spite  of  the  most  careful  en- 
forcement of  the  use  of  masks,  gauntlets,  etc.,  in  i  year  there  were  nearly 
400  accidents.  The  number  of  bottles  that  burst  in  i  year  is  very  consid- 
erable; new  bottles  or  syphons  are  twice  as  liable  to  break  as  the  old  ones. 
About  I  per  cent,  of  the  new  and  old  bottles  break  when  filled.  Syphons 
burst  less  frequently  but  the  explosion  and  danger  is  greater;  about  one  in 
5000  breaks  in  winter,  while  the  percentage  is  greater  in  hot  weather.  The 
greater  number  of  bottles  break  in  the  filling  machine  but  there  is  prac- 
tically no  work  in  any  part  of  the  factory  which  may  be  regarded  as  free  from 
danger. 

Certain  forms  of  injury  are  more  apt  to  happen  to  some  parts  of  the  eye 
than  others.  Cuts  and  gashes  occur  mostly  upon  the  anterior  portion  of  the 
eye  and  its  protecting  organs;  the  lids,  globe,  cornea,  ciliary  region.  Perfor- 
ating wounds  may  go  from  the  cornea  and  sclera  through  the  bulb  into  the 
orbit  and  the  optic  nerve.  Lacerations,  tears,  and  the  wounds  from  the  bites 
of  animals,  are  upon  the  more  exposed  parts,  while  shot  wounds  affect  all 
portions  of  the  eye.  Flying  foreign  bodies  or  motes  are  usually  found  under 
the  lids,  though  they  may  be  impacted  in  the  outer  part  of  the  bulb,  especially 
the  cornea.  These  consist  of  cinders,  iron  and  copper  splinters,  the  latter  of 
which  are  often  imbedded  in  the  anterior,  or  ev^en  go  to  the  posterior  portion 
of  the  eye,  remaining  in  the  iris,  vitreous,  or  the  coats.  The  cornea  most 
often  contains  foreign  bodies,  less  often  the  conjunctiva  and  sclera.  The 
effects  of  blows  is  most  apparent  upon  the  outer  portion^,  the  lids,  brow,  and 
then  the  bulb.  In  the  eye  itself  the  blow  may  cause  tearing  of  the  retina  and 
chorioid,  indenting  the  eye,  and  may  push  the  lens  away,  causing  detachment. 
Burns  and  cauterizations,  as  a  rule,  affect  only  the  outer  structures,  the  Hds, 
cornea,  and  conjunctiva.  The  same  may  be  said  of  burns  from  flame,  the 
effect  of  Hghtning,  electricity  and  sunlight,  which  may  affect  the  lens  and  also 
the  retina. 


312  OCCUPATIONAL    AFFECTIONS    OF    THE    NOSE,    MOUTH,    ETC. 

OBJECTS  CAUSING  OCULAR  INJURIES 

On  account  of  the  great  sensitiveness  of  the  cornea,  the  formation  of  scar 
tissue  and  the  danger  of  infection,  a  very  small  solution  of  continuity  of  this 
membrane  is  of  great  importance.  All  substances  which  come  into  contact 
with  the  surface  of  the  cornea  are  apt  to  cause  erosions.  These  may  occur 
from  the  finger  nail,  pieces  of  straw  and  twigs.  Cuts  of  the  eye  obtain  from 
sharp  instruments,  such  as  knives,  shears,  glass;  thin  points  of  metal  such  as 


Fig.  14. — Men  pouring  babbitt  should  wear  goggles  or  a  wire  mesh  screen  covering  the  face, 
as  at  any  moment  an  explosion  is  liable  to  occur.     U.  S.  Steel  Corp'n.     {Wiirdemann.) 


tin,  and  all  cutting  substances.  Piercing  wounds  also  occur  from  sharp 
points  of  metal,  wood,  and  glass,  which  are  round  and  thin,  such  as  needles, 
pins,  awls,  nails,  pieces  of  wire,  forks  and  other  table  instruments,  thorns, 
styles,  or  animal's  claws;  or  those  pointed,  but  not  specially  sharp  instruments, 
as  daggers,  poinards,  swords,  sabers,  bayonets,  knives,  steel  pens;  or  those 
long  triangular  or  irregular,  as  the  points  of  compasses,  sharp-pointed  pieces 
of  wood,  pencils,  sticks,  parasols,  walking  canes,  and  umbrellas.  Gashes  are 
formed  by  knives,  chisels,  sabers,  axes,  daggers,  etc. 

Contused  wounds  are  caused  by  either  sharp  or  blunt  objects  of  iron, 


OCCUPATIONAL    INJURIES    AND    DISEASES    OF    THE    EYE  313 

wood  or  other  stuff;  by  flying  pieces  of  such  substances  as  iron,  nails,  pieces  of 
horseshoes,  and  all  substances  used  in  iron  works;  by  files,  pieces  of  wood, 
sticks,  stone,  shell,  etc.  Such  may  also  occur  by  the  horns  and  hoofs  of 
cattle,  the  beaks  of  birds,  which  cause  combined  tearing  and  contusion.  A 
large  number  of  cases  of  whip-lash  injuries  have  been  reported.  Lacerating 
wounds  obtain  through  the  above  objects  but  are  not  particularly  due  to 
injuries  by  machinery,  hooks,  nails,  or  to  the  teeth  and  claws  of  dogs  and  cats. 
Bite-wounds,  however,  are  generally  due  to  dogs,  except  in  rare  cases  of 
hunting  accidents  where  they  occur  from  boars,  bears,  and  wildcats. 

Foreign  bodies  either  remain  superficially  or  go  deeply  into  the  eye  or 
orbit.  They  are  carried  by  either  the  air  or  the  wind,  faUing  upon  the  eye,  as 
cinders,  particles  of  stone,  coal  or  wood  ashes,  pieces  of  grain  or  sawdust — the 
so-called  domestic  accidents. 

Industrial  injuries  are  due  to  machinery  or  hand-work,  and  as  a  rule  are 
from  pieces  broken  loose  from  objects  and  go  more  deeply  into  the  structure  of 
the  eye  or  into  its  interior.  These  are  particles  of  iron,  coal,  copper,  slate, 
stone,  wood,  bone,  and  those  foreign  bodies  which  are  driven  by  explosions, 
such  as  glass  spHnters  from  exploding  retorts,  pieces  of  copper  from  caps  or 
cartridges,  etc. 

Contusions  occur  from  blunt  or  round  objects,  as  a  rule  of  large  size;  from 
falls  on  furniture,  blows  of  fists,  instrument  handles,  etc.,  or  from  objects 
which  have  been  thrown  with  force,  as  stones,  baseballs,  tennis  balls,  snow- 
balls, potatoes,  apples,  etc.;  also  from  corks,  glasses,  concentric  tops  of  bot- 
tles from  explosion  of  the  same. 

Burns  are  caused  by  the  flame  itself,  by  the  sun  or  electric  fight,  from  glow- 
ing rods  and  glass,  by  hot  but  not  melted  metal,  by  hot  ashes,  grains  of 
powder,  burns  of  the  hair,  from  burning  gas  and  hot  steam,  from  hot  water, 
oil,  petroleum,  pitch,  etc.  Cauterization  may  be  due  to  acids,  such  as  sul- 
phuric, nitric,  hydrochloric,  phenol,  vitriol,  to  alkalies  and  caustics,  as  soda 
and  potash,  to  lime  burns,  arsenate  of  lead,  and  to  methyl  violet  pencils  and 
other  substances. 

BACTERIOLOGY 

The  aspergillus  fumigatus  is  the  only  mould  that  has  been  found  to  cause 
infection  of  ocular  wounds.  The  micrococci  occur  in  the  following  order: 
the  diplo-pneumococcus,  streptococcus  pyogenes,  staphylococcus  pyogenes, 
aureus  and  albus.  The  ozena  bacillus,  gonococcus,  bacillus  pyocyaneus, 
bacillus  pyogenes,  staphylococcus  pyogenes,  citreus  and  fetidus,  micrococcus 
cereus,  tetragenus  prodigiosus,  and  bacillus  of  tetanus  are  less  often  found. 
To  these  perhaps  may  be  later  added  the  presently  unknown  microorganism 
producing  sympathetic  ophthalmitis. 

Staphylococci  are  constantly  found  in  the  skin  at  the  edge  of  the  lid  and 
sometimes  in  the  normal  conjunctival  sac;  strep toccoci  and  pneumococci  are 
never  found  in  the  normal  eye.] 


314         OCCUPATIONAL  AFFECTIONS   OF   THE   NOSE,   MOUTH,   ETC. 

DISPOSITION  OF  DISEASED  AND  ABNORMAL  EYES  TO  INJURY 

Weak  sight  disposes  to  bodily  injury,  because  the  individual  does  not 
see  well  enough  to  escape  accidents,  as  well  as  specific  injuries  to  the  eyes. 

Diseased  and  abnormal  eyes,  as  in  those  suffering  from  senile  degeneration 
and  weakened  walls  of  the  blood-vessels,  are  predisposed  to  bleeding  into 
the  tissues  from  contusions  and  concussions,  and  to  this  condition  persons 
suffering  from  arteriosclerosis,  glaucoma,  diabetes,  leukemia,  and  renal  dis- 
eases are  likewise  subject. 

TRAUMATISM  AS  AN  EXCITING  CAUSE  OF  CONSTITUTIONAL 

EYE  DISEASE 

Traumatism  may  be  the  exciting  cause  of  syphihtic  iritis  and  it  is  possible 
that  a  corneal  wound  may  be  the  point  of  entrance  for  an  exogenous  infection, 
or  a  syphilitic  iritis  may  be  superimposed  on  an  iritis  from  other  cause. 

MECHANISM  OF  SPECIAL  TYPES  OF  INJURIES 

Incised,  piercing,  and  flap  wounds  are  produced  by  sharp  instruments 
or  objects  apphed  with  more  or  less  force;  while  contused,  lacerated,  and 
bite  wounds  are  more  often  of  the  nature  of  tears  produced  by  blunt 
instruments. 

Small  objects,  as  motes  may  be  borne  by  the  wind,  carried  to  the  eyes, 
stick  to  the  conjunctiva,  and  become  impacted  therein,  or  are  carried  under 
the  lids  and  by  rubbing  may  be  impacted  into  the  cornea.  Others  come  with 
force  from  the  breaking  of  an  object  and  are  impacted  directly,  or,  if  hot, 
burn  themselves  a  place  in  the  tissues. 

Explosions  of  firearms,  powder  and  dynamite  result  in  the  impaction  of 
foreign  bodies,  not  only  from  the  exploding  compound,  but  also  from  sur- 
rounding objects. 

Contusions  cause  both  direct  and  indirect  damage;  the  direct  by  impaction 
of  the  object;  the  indirect  from  rebound  of  the  tissues  from  the  elastic  contents 
of  the  orbit  and  its  bony  walls.  Ruptures  occur  through  compression  and 
inward  pressure,  which,  when  the  coefl&cient  of  resistance  of  the  structure  is 
reached,  causes  disassociation  of  contiguity  and  bursting.  If  the  structure 
gives  under  the  force,  it  breaks  away  from  its  surroundings  and  direct  rup- 
ture with  dislocation  results. 

Rupture  of  the  cornea  or  sclera  is  produced  by  the  pressure  of  the  foreign 
body  being  so  distributed  that  there  is  no  place  for  the  globe  to  go  and  it 
thus  bursts. 

In  direct  rupture  the  break  occurs  at  the  point  of  pressure  in  another  part 
of  the  globe.  The  mechanisms  of  corneal,  scleral,  iridic  and  chorioidal 
ruptures  are  under  the  anatomic  heading. 

The  mechanism  is  mostly  that  of  burning,  in  solar  that  of  burning  com- 


OCCUPATIONAL   INJURIES    AND    DISEASES    OF    THE    EYE  315 

bined  with  the  electro-chemic  effects  of  ultraviolet  light,  in  electric  injuries 
burning,  hght,  and  electrolysis,  and  in  some  instances  the  effect  of  concussion. 

The  effect  of  explosions  of  gunpowder  and  dynamite,  and  of  firearms, 
causes,  through  a  combination  of  wounds,  with  and  without  penetration  of 
foreign  bodies,  contusion,  concussion,  ruptures,  burning  and  infection. 

Infected  wounds  have  the  characteristics  of  other  wounds,  combined  with 
loss  of  tissue  from  ulceration  due  to  necrosis,  following  the  development  of 
microorganism  within.  The  infection  may  be  carried  by  the  object  pro- 
ducing the  injury,  by  accompanying  foreign  bodies,  exposure  to  the  air, 
or  by  contact  with  fingers,  unclean  instruments,  medicaments,  or  bandages. 

PROPHYLAXIS  OF  INJURIES  OF  THE  EYE 

While  many  eye  accidents  are  unavoidable,  yet  the  large  majority  are 
preventable  by  due  care  of  the  patient,  parents,  fellow- workmen  or  employers. 

In  agricultural  life  many  accidents  occur  from  carelessness,  as  injuries 
from  baling  wire,  straw,  hooks,  branches,  splitting  wood,  horning  from  cows, 
kicks  from  cows,  horses,  etc.,  most  of  which  are  to  be  avoided  by  due  care. 

Safeguards  against  accidents  to  workingmen  have  been  forced  upon  the 
attention  of  manufacturers,  transportation  companies  and  others,  not  only 
by  legal  measures,  but  by  the  necessity  for  conservation  of  their  own  goods 
and  machinery,  the  loss  of  service  and  the  cost  of  care  and  expense  in  treat- 
ment of  such  workingmen,  as  well  as  protection  from  damage  suits,  which 
give  lawyers  lots  of  work.  The  policy  of  making  factory  work  safer  and  more 
healthful  is  profitable  as  well  as  humane,  and  it  makes  the  workman  more 
contented.  Safety  appliances  are  in  use  in  most  dangerous  trades  and  have 
markedly  decreased  the  proportion  of  accidents,  particularly  of  the  eye. 
Note  the  lessened  number  of  blind  from  accidents  within  the  last  10  years. 
But  it  is  with  reluctance  that  the  workman  uses  them  and  he  will  shirk 
their  application  unless  carefully  watched  and  continuously  warned.  Even 
if  protectors  hang  alongside  of  the  grindstone  they  are  rarely  used.  There 
are  a  variety  of  protectors  in  the  market.  Gauze  wire,  fitting  close  to  the 
eye  like  a  cup  and  attached  to  the  head  by  a  string,  is  employed  by  stone 
breakers,  and  in  some  iron  works.  The  mesh  should  be  sufficiently  strong 
and  fine,  and  sufficiently  close  to  prevent,  as  far  as  possible,  even  small 
chippings  passing  through  it,  and  yet  to  interfere  with  sight  as  little  as 
possible. 

Large  heavy  glasses  made  of  plain  glass  with  heavy  frames  are  used  by 
stone  masons;  plain  glass  with  leather  fittings  for  workers  in  chemicals  and 
in  lime  works  where  the  acrid  fumes  may  affect  the  eyes.  Automobile  pro- 
tectors are  now  in  common  use  for  out-of-door  people  using  these  vehicles. 

Amber,  novial,  Crookes'  and  even  plain  white  glass  not  only  offer 
protection  from  small  flying  objects,  but  in  a  great  measure  cut  off  the  violet 
or  chemical  rays. 


3i6 


OCCUPATIONAL   AFFECTIONS    OF    THE    NOSE,    MOUTH,    ETC. 


Where  grinders  or  workmen  in  the  iron  trades  sharpen  their  tools  a 
number  of  times  a  day  at  the  wheel,  thousands  of  foreign  bodies  fly  about, 
many  of  which  strike  the  person  despite  safety  appliances  that  may  be  used. 
I  have  in  my  possession  a  pair  of  ordinary  spectacles  used  by  a  workman, 
which  is  completely  studded  with  hundreds  of  abrasions  caused  by  flying 
particles  of  emery — a  not  uncommon  observation. 

If  one  examine  carefully  the  cornea  in  the  eye  of  a  grinder  he  may  be  sur- 
prised to  find  a  large  number  of  specks,  which  are  the  results  of  previous  in- 


FiG.  15.^ — Men  at  emery  wheel  should  at  all  times  wear  goggles  even  if  wheel  has  a 
permanent  glass  guard.     U.  S.  Steel  Corp'n.     {Wiirdcmann.) 


juries.  If  they  be  situated  without  the  visual  area  they  give  rise  to  no  incon- 
venience, but  if  in  the  visual  axis,  a  very  small  scar  may  cause  decided  lower- 
ing of  the  visual  acuity.  All  such  trivial  accidents  could  be  prevented  by 
the  workingman  wearing  protection  while  at  such  forms  of  work. 

The  use  of  the  pneumatic  chipper  has,  in  many  cases,  almost  superseded 
the  hand  chipping  by  sate  and  hammer,  and  thus  the  dangers  of  chipping 
are  largely  avoided.  It  accomplishes  in  i  hour  what  would  take  6  hours 
by  hand,  and  prevents  the  flying  about  of  fragments,  as  it  is  more  like  run- 
ning a  scoop  over  fairly  soft  cheese  than  using  a  tool  on  hard  steel. 

The  proper  arrangement  of  men  at  their  work  and  the  use  of  screens 


OCCUPATIONAL    INJURIES    AND   DISEASES    OF    THE    EYE  317 

to  avoid  injury  to  their  fellow-workmen  and  to  passers-by  have,  together 
with  the  wearing  of  proper  eye  protectors,  conserved  the  safety  of  sight  in 
factories  where  such  have  been  installed  and  made  obligatory. 

My  experience  has  shown  that  there  is  less  difficulty  in  enlisting  the  sup- 
port of  the  employers  than  the  assent  of  the  men  to  adopt  precautionary 
measures. 

PROTECTIVE  LEGISLATION 

Our  own  workmen  are  protected  by  various  laws  for  the  regulation  of 
machinery,  of  different  natures  in  the  several  states,  and  in  the  case  of  public 
carriers,  as  the  railway  and  steamship  companies,  by  the  Interstate  Com- 
merce Commission  and  by  their  own  stringent  rules,  which,  however,  have 
more  to  do  with  conservation  of  the  public  safety  and  their  own  goods  and 
machinery  than  with  the  individual  workman. 

Study  of  the  appalling  hst  of  accidents  occurring  annually  in  American 
industries  has  led  employers  to  install  many  modern  devices  for  making 
factory  work  safer  and  more  healthful.  The  policy  of  doing  this  is  profitable 
as  well  as  humane,  for  it  makes  workmen  brisker  and  more  contented. 

Devices  have  been  put  into  use,  moreover,  to  prevent  accidents,  and  pro- 
vision has  been  made  to  attend  to  the  men  injured  when  accidents  occur. 
Ten  years  ago  an  accident  would  drive  a  factory  engineer  away  from  his 
throttle  at  the  critical  moment.  Nowadays  a  factory  girl  can  shut  down 
the  most  ponderous  engine  by  pressing  a  button.  Accidents  do  happen, 
however,  many  of  them.  In  the  best  regulated  factories  the  victim  goes 
to  the  factory  hospital. 

In  case  of  negligence  being  shown  on  the  part  of  the  employer  by  reason 
of  defective  tools,  surroundings,  or  placing  the  men  at  extra  dangerous  work 
for  which  they  have  not  specially  contracted  and  from  which  circumstances 
accidents  arise,  the  workmen  are  entitled  by  law  to  recover  some  compen- 
sation. In  all  such  suits,  however,  the  compensation  asked  for  is  more,  and 
ofttimes  many  times  the  amount,  than  should  be  allowed.  We  claim  that 
all  compensation,  not  alone  that  to  be  given  as  the  result  of  claims  at  law 
but  also  claims  for  insurance,  should  be  regulated  by  the  amount  of  the 
economic  damage. 

By  the  term  "workmen's  compensation  laws"  is  meant  enactments 
which  embody  the  principle  that  the  workman  is  entitled  to  compensation 
for  injuries  received  in  the  course  of  his  employment.  Such  laws  have  been 
enacted  in  31  states  of  the  American  Union,  Alaska,  Hawaii  and  the 
Panama  Zone,  but  are  far  from  uniform,  showing  the  widest  diversities  in 
the  methods  and  amounts  of  compensation  and  scope  of  the  laws. 

Usually  the  injuries  must  cause  disablement  for  a  specified  number  of 
days  or  weeks  before  compensation  becomes  due.  The  employer  may 
usually  be  relieved  ftom  the  payment  of  compensation  if  he  can  prove  that 
the  injury  was  caused  intentionally  or  by  willful  misconduct,  or,  in  some 


3l8  OCCUPATIONAL   AFFECTIONS    OF   THE   NOSE,    MOUTH,    ETC. 

countries,  by  the  gross  negligence  of  the  injured  person  or  during  the  per- 
formance of  an  illegal  act. 

The  industries  usually  covered  by  the  acts  occur  in  manufacturing, 
mining  and  quarrying,  transportation,  building  and  engineering  work,  and 
other  employments  involving  more  or  less  hazard.  In  Belgium,  France 
and  Great  Britain  the  laws  apply  to  practically  all  employments.  In  Austria, 
Norway,  Russia,  Spain  and  Sweden  only  workmen  engaged  in  actual  manual 
work,  and  in  some  cases  those  exposed  to  the  same  risks,  such  as  overseers 
and  technical  experts,  come  within  the  operations  of  the  law.  On  the  other 
hand,  in  France,  Great  Britain,  the  British  colonies,  and  Hungary  the  laws 
apply  to  salaried  employees  and  workmen  equally.  Overseers  and  technical 
experts  earning  more  than  a  prescribed  amount  are  excluded  in  Belgium, 
Denmark,  Germany,  Great  Britain,  Italy,  Luxemberg  and  Russia.  Em- 
ployees of  the  state,  provincial  and  local  administrations  usually  come 
within  the  provisions  of  the  act. 

The  entire  burden  rests  upon  the  employer  in  all  but  four  countries — • 
Austria,  Germany,  Hungary  and  Luxemberg,  where  the  employees  bear  part 
of  the  expense.  The  laws  in  every  case  iix  the  compensation  to  be  paid. 
Except  in  Sweden  the  compensation  is  based  upon  the  wages  of  the  injured 
person.  It  consists  of  medical  and  surgical  treatment  and  periodical  allow- 
ances for  temporary  disability,  and  annual  pensions  or  lump  sum  payments 
for  permanent  disability  or  death. 

In  America  and  in  other  countries  the  estimation  of  the  damage  done  by 
accidents  in  legal  cases  is  left  to  the  empirical  dictum  of  the  judge,  who  is 
guided  by  precedent,  and  to  the  sympathies  or  prejudices  of  the  jury,  which 
may  be  aroused  by  the  attorney  presenting  the  case,  pain  of  body  and  anguish 
of  mind  being  apparently  very  important  factors. 

Diagnosis  of  Injuries  to  the  Eye. — The  diagnosis  of  injuries  to  the  eye 
is  made  by  subjective  and  objective  examinations,  of  which  the  history, 
symptomatology,  and  the  visual  acuity,  field,  condition  of  the  ocular  muscula- 
ture and  the  refraction  are  given  their  proper  consideration. 

Objective  examination  by  direct  and  focal  illumination,  the  ophthalmo- 
scope, diaphanoscope,  sideroscope,  magnetic  attraction  and  the  X-ray  offer 
exact  means  of  diagnosis. 

A  careful  history  should  be  obtained,  giving  the  date  and  hour  of  the 
accident,  the  character  of  the  work  and  surroundings,  the  instrument  con- 
cerned, object  or  foreign  body  causing  the  lesion,  and,  in  special  cases,  the 
names  of  the  witnesses  to  the  accident;  also  the  character  of  attempts  to 
remove  a  foreign  body,  and  whether  or  not  the  case  has  been  attended  by  a 
physician,  are  facts  that  should  be  elicited.  Remember  that,  while  the 
interests  of  the  patient  are  of  prime  importance,  we  should  be  guarded  in  our 
prognosis,  as  it  depends  very  largely  upon  previous  injuries  and  the  character 
of  the  first  dressing.  We  should  never  give  an  opinion  reflecting  upon  the 
first  consultant,  or  as  to  the  liability  of  the  employer,  for  these  are  theories 


OCCUPATIONAL   INJURIES    AND    DISEASES    OF    THE    EYE  319 

that  the  lawyers  may  be  allowed  to  fight  about  and  the  courts  decide.  The 
less  we  have  to  do  with  the  legalized  human  parasites  who  are  in  the  habit  of 
soliciting  personal  damage  suits,  the  better  it  is  for  the  physician,  and  we 
should  not  furnish  information  in  advance  upon  which  a  personal  damage  or 
malpractice  suit  might  be  based. 

Usually  an  examination  may  be  conducted  without  a  local  anaesthetic,  as 
cocaine  or  holocaine,  but  such  are  frequently  needed  to  subdue  irritability, 
adrenalin  to  lessen  congestion,  and  cocaine,  homatropine,  euphthalmine,  or 
atropine  for  mydriasis.  The  visual  acuity,  and  in  some  cases  the  visual  field, 
muscle  balance,  duction  and  versions,  the  refraction,  etc.,  should  be  ascer- 
tained. In  fact,  in  medico-legal  cases  a  full  examination  should  always  be 
made,  and  sketch  drawings  or  water  colors  may  be  made,  as  well  as  full  notes 
taken.  The  literature  of  the  subject  should  be  looked  up,  as  then  the  exam- 
iner, as  a  medical  witness,  will  be  fully  prepared  for  his  answers  in  court. 
The  demeanor,  wiUingness  of  the  patient  and  actions  of  his  companions 
should  be  noted  as  thereby  hints  as  to  malingering  may  be  ascertained. 

The  examination  of  an  injured  person  from  a  medico-legal  standpoint 
should  be  conducted  in  a  sympathetic  manner  in  order  to  obtain  the  patient's 
confidence,  and  while  the  examiner  should  ever  be  on  the  watch  for  malinger- 
ing, yet  he  should  not  take  an  antagonistic  stand.  Such  an  examination  is 
often  grudgingly  submitted  to,  the  patient  looking  upon  the  examiner  in  the 
light  of  an  opponent  who  has  been  hired  by  the  defense  to  find  some  excuses 
for  prevention  of  the  collection  of  damages. 

The  opposite  frame  of  mind  is  shown  by  those  injured  persons  who  them- 
selves secure  an  examination  as  a  basis  for  malpractice,  or  personal  injury 
suit.  Yet  they,  too,  invariably  distort  and  magnify  the  importance  of  the 
economic  damage. 

It  behooves  us,  therefore,  in  examination  of  injury  cases,  to  leave  no 
impression  upon  the  patient  as  to  the  ad\'isability  of  his  seeking  recourse  at 
law,  but  to  conduct  the  examination  in  an  impartial  and  sympathetic  manner, 
at  the  same  time  leaving  a  favorable  opinion  upon  his  mind. 

A  comparatively  smaU  proportion  of  accidental  injuries  have,  in  American 
law,  a  basis  for  collection  of  damages;  the  larger  number  have  been  worked 
up  for  pecuniary  rather  than  eleemosynary  purposes.  Be  this  as  it  may,  one 
should  not  lose  sight  of  the  fact  that  cases  occur  in  which  there  are  really 
grounds  for  damages  and  which  should  obtain  pecuniary  reUef  thereby. 

Owing  to  the  transparency,  translucency,  and  deHcacy  of  the  ocular 
structures  a  number  of  special  methods  of  examination  are  of  help,  of  which 
general  inspection  by  direct  and  reflected  light  should  first  be  used. 

Objective  Examination. — Inspection  by  direct  illumination  by  daylight, 
electric  fight  or  reflecting  mirror  is  first  made.  The  skin,  fids,  cornea,  con- 
junctiva, puncta,  lacrimaha,  etc.,  are  observed.  Then  the  retrobulbar 
folds  and  undersurface  of  the  lids  are  brought  into  view  by  eversion  with  the 
fingers,  but  preferably  by  pushing  down  the  retrotarsal  folds  by  a  smooth 


320  OCCUPATIONAL    AFFECTIONS    OF    THE    NOSE,    MOUTH,    ETC. 

instrument,  as  a  small  glass  rod,  handle  of  an  instrument,  or  cotton-tipped 
stick,  as  it  is  here  that  most  diseases  of  the  conjunctiva  are  prominent  and 
foreign  bodies  may  be  impacted  therein. 

Many  small  and  otherwise  almost  indistinguishable  abrasions  of  the 
corneal  epithelium,  wounds  and  small  foreign  bodies  in  the  cornea,  may  be 
brought  into  view  by  the  staining  of  the  tissues  with  a  2  per  cent,  fluorescein 


Fig.  16. — A  dangerous  practice  which  should  be  absolutely  forbidden,  and  which 
causes  much  infection.  When  injured  report  at  once  to  the  emergency  hospital.  U.  S. 
Steel  Corp'n.     (W iirdemann.) 


and  2  per  cent,  bicarbonate  of  soda  solution.  This  aniline  dye  will  not 
stain  the  intact  corneal  epithelium,  but  readily  passes  into  the  subjacent 
parenchyma  and  abraded  epithelial  cells,  forming  a  bright  green  background 
upon  which  foreign  bodies  are  readily  perceived. 

Magnification  of  the  eye  by  a  lens,  preferably  by  the  Berger  or  Jackson 
binocular  loupe,  is  of  great  value. 


OCCUPATIONAL   INJURIES    AND    DISEASES    OF    THE    EYE  321 

Focal  illumination  in  the  dark  room  is  ordinarily  carried  out  by  focusing 
the  light  upon  the  eye  by  a  large  loupe.  The  use  of  the  diaphanoscope  for 
this  purpose  gives,  however,  a  much  better  illumination,  as  the  light  is  con- 
fined to  a  narrow  beam.  The  author's  transilluminator  is  the  size  of  an  ordi- 
nary fountain  pen  and  is  as  readily  handled. 

The  ophthalmoscope  should  first  be  used  at  a  distance  of  a  couple  of 
feet  from  the  eye  and  magnification  obtained  by  use  of  a  +3.00  to  +16.00 
lens  in  the  instrument,  the  patient  being  directed  to  look  in  various  directions, 
whereby  a  foreign  body  may  be  brought  into  view  against  the  red  background 
of  the  fundus;  approaching  closer  to  the  eyes,  after  the  cornea  and  anterior 
chamber  have  been  examined  in  this  manner,  the  lens,  vitreous,  and  fundus  are 
then  successfully  investigated.  The  electric  ophthalmoscope  with  light 
regulated  by  a  rheostat  gives  the  most  elastic  means  of  such  examination. 

Diaphanoscopy  is  a  means  of  rendering  the  eyeball  luminous,  whereby  the 
shadow  of  the  cihary  body,  iris,  tumor,  or  large  foreign  body  within  the  eye 
may  be  observed.  I  have  a  number  of  times  determined  the  presence  of 
foreign  bodies  which  were  at  first  indiscernable  by  other  methods  behind  the 
iris,  in  the  lens  or  in  the  fundus  by  this  method. 

The  sideroscope,  if  properly  made  and  mounted,  will  determine  the  presence 
of  a  foreign  body,  but  it  must  be  magnetic,  and  the  accuracy  with  which  you 
are  able  to  locate  foreign  bodies  within  the  eye  often  varies  from  i  to  3  cm. 

"The  instrument  is  a  marvel  of  delicacy,  but  to  handle  it  requires  the 
patience  of  a  saint." 

The  giant  magnet  will  reveal  the  presence  of  magnetizable  pieces  of  steel 
and  iron  by  causing  traction  within  the  eye,  varying  from  a  drawing  sensation 
to  decided  pain  on  approach  of  the  eye  to  the  magnet.  The  foreign  body  may 
likewise  be  drawn  into  view,  or  the  eye  may  adhere  or  curve  forward  toward 
the  magnet  if  the  body  be  sufficiently  large.  Such  a  method  of  examination 
is,  however,  somewhat  dangerous,  on  account  of  the  foreign  body,  while 
approaching  the  magnet,  acting  as  a  missile  and  tearing  structures  that  might 
not  have  been  previously  injured.  In  such  examination  the  eye,  needless  to 
say,  should  not  be  anaesthetized. 

The  increasing  use  of  magnesium  and  nickel  steel  renders  the  number 
of  non-magnetizable  foreign  bodies  somewhat  larger  in  proportion  than 
previously. 

The  exact  determination  of  the  existence,  position  and  size  of  foreign 
bodies  within  the  globe  has  only  become  possible  since  the  advent  of  the 
Rontgen  rays. 

As  the  frequency  of  injuries  to  the  eye  from  flying  copper  increases  in 
number  each  year,  due  to  more  extended  use  of  that  metal,  largely  from  the 
increased  use  of  electricity,  the  value  of  accurate  radiographs  becomes  more 
apparent. 

In  a  series  of  experiments  to  determine  the  degree  of  penetration  of  the 
X-rays  to  various  substances,  such  as  glass,  marble,  granite,  cement,  etc.. 


322  OCCUPATIONAL   AFFECTIONS    OF    THE    NOSE,    MOUTH,   ETC. 

Sweet  placed  particles  of  these  substances  in  the  inner  canthus  of  a  cocanized 
eye.  The  size  of  each  was  approximately  2  X  2^  mm.  The  result  shows 
that  all  of  these  substances  can  be  made  visible  if  proper  technique  be  followed. 
The  figures  show  the  density  of  shadows  of  each  materials,  the  exposure 
being  the  same  for  all  materials,  coal  being  the  only  one  used  that  failed  to 
demonstrate  a  shadow  of  any  usefulness. 

Accidental  injuries  to  the  eyes  may  be  imitated  by  the  patient  putting  in 
medicinal  or  irritative  substances  or  wounding  or  otherwise  causing  actual 
injuries  to  his  own  eyes  (self-inflicted  damage),  or,  what  is  more  commonly 
the  case,  alleging  loss  of  sight  or  other  function  or  liability  to  use  the  eyes,  or 
painful  affections  (simulation),  or  overstating  the  degree  of  damage  to  the 
function  of  sight  (aggravation) — all  of  which  classes  under  the  generic  term  of 
malingering. 

More  difficult  to  determine  are  those  cases  where  the  existence  of  acci- 
dental lesion  is  apparent  in  which  the  injured  party  claims  greater  functional 
damages  than  actually  exists  in  the  individual.  A  number  of  observations 
should  here  be  made  in  order  to  determine  the  proper  relations. 

THE  RELATION  BETWEEN  ACCIDENTAL  INJURIES  AND  PREVI- 
OUSLY INTERCURRENT  AND  POST -TRAUMATIC  CHANGES 

IN  THE  EYE 

Conditions  due  to  an  accidental  injury  must  be  differentiated  from  those 
existing  before,  those  concurrent  with,  or  those  occurring  after  the  injury 
from  other  causes. 

In  uncomplicated  fresh  cases,  blemishes  due  to  previously  existing 
disease,  or  the  results  of  former  accidents,  are  readily  determined,  but  espe- 
cially those  which  come  to  the  examiner  a  long  time  after  the  alleged  injury; 
such  may  not  be  so  evident,  and  afford  weighty  problems. 

It  is  especially  necessary  in  these  cases  to  make  a  general  examination  of 
the  body  and  to  carefully  note  the  condition  in  the  non-injured  eye.  In  the 
injured  organ  note  whether  typical  scars  or  inflammatory  changes  or  their 
effects  are  to  be  seen. 

Many  persons  suddenly  discover  that  they  cannot  see  well  with  one  or 
both  eyes  after  an  accident,  whereas  from  myopia,  high  astigmia,  hyperopia, 
or  even  presbyopia  they  have  previously  been  poor  sighted  and  have  not 
known  of  the  condition.  Some  are  honest  in  their  claims;  other  seize  the 
opportunity  afforded  by  an  accident  to  blame  the  deficiency  upon  the 
alleged  trauma. 

THE  RESPONSIBILITY  OF  THE  PHYSICIAN 

Legally,  the  physician  may  be  said  to  have  no  responsibility,  as  regards 
prognosis,  and  this  is  a  matter  of  personal  opinion  rather  than  of  fact,  but 
ethically  his  position  is  one  which  is  twofold.     From  his  own  standpoint  and 


OCCUPATIONAL   INJURIES    AND    DISEASES    OF    THE    EYE  323 

that  of  the  patient's  good  it  is  necessary  that  the  patient  retain  a  favorable 
opinion  of  the  physician  and,  in  many  cases,  continue  to  take  treatment. 
Thus,  by  an  unfavorable  prognosis  which  may  not  prove  to  be  true — for 
wonderful  are  the  ways  of  Nature  in  curing  disease  and  healing  injury — the 
physician  may  be  discredited  by  a  partial  or  complete  restoration  to  health 
of  the  patient.  Pecuniarily  he  may  suffer  as  a  result  of  the  patient  leaving 
him  to  go  to  some  other  physician  who  gives  a  more  favorable  prognosis. 
Secondarily  the  effect  upon  the  patient's  mind  is  one  that  should  be  con- 
sidered, and  hope  should  always  be  afforded  to  what  is  esteemed  the  hopeless 
cases.  While  the  whole  truth  should  be  told  the  family  physician  and  to  the 
family  of  the  patient,  yet  the  whole,  and  what  may  be  most  unpalatable, 
truth  need  not  be  told  the  patient  himself.  This  has  to  be  learned  by  experi- 
ence in  the  most  unpleasant  manner  by  the  average  physician  as  the  result  of 
an  unfavorable  prognosis. 

Prognosis  of  Tnjtiries  to  the  Eye. — The  prognosis  of  ocular  injuries  depends 
largely  upon  the  part  of  the  eye  that  is  damaged,  more  especially  that  having 
to  do  with  the  function  of  sight.  Of  first  importance  is  the  central  visual 
acuity;  secondly,  the  visual  field;  thirdly,  the  ocular  movements;  and  lastly, 
the  light  and  color  sense.  To  these  may  be  added  the  cosmetic  damage  and 
the  ability  to  use  the  eyes  for  work,  or,  as  Magnus  puts  it,  the  abiUty  to 
compete;  and  the  sum  of  them  all  results  in  the  economic  vision. 

Trauma  acting  on  the  parts  of  the  eye  necessary  for  clear  vision,  as  the 
visual  zone  of  the  cornea,  the  lens,  vitreous,  macula  lutea,  does  more  damage 
in  proportion  than  that  to  one  side,  and  offers  a  more  unfavorable  prognosis 
on  account  of  resultant  obstruction  to  vision.  Injuries  to  the  optic  nerve 
and  visual  sphere  are  usually  followed  by  atrophy  and  blindness.  Injuries 
of  the  cihary  region  are  provocative  of  sympathetic  ophthalmitis  and  loss 
of  the  other  eye  as  well.  As  a  rule,  clean-cut  wounds  heal  well  if  not  infected. 
Infection  may,  as  a  rule,  be  successfully  combated  if  seen  in  the  early  stages. 
Retained  foreign  bodies  are  always  dangerous.  Contusions  are  generally 
dangerous,  as  they  lead  to  secondary  degenerative  changes  and  detachment 
of  the  retina.  Burns  of  the  anterior  portion  of  the  globe  are  always  to  be 
feared,  lime  injuries  especially.  Electrical  injuries  result  in  primary  or 
secondary  damage  to  the  lens  and  retina.  Double  perforating  wounds  of  the 
globe,  even  with  retained  foreign  bodies  behind  in  the  orbit,  are  compatible 
with  comparatively  small  amount  of  damage  to  the  function. 

Local  fractures  of  the  orbital  walls  are  of  less  moment,  quoad  vitam,  than 
those  which  extend  along  the  base  of  the  brain. 

The  future  prospects  for  eyes  that  have  been  injured  opens  a  wide  and 
doubtful  field  for  prognosis,  but  as  the  physician  is  frequently  asked  in  court 
concerning  prognosis,  and  as  this  is  a  matter  of  constant  inquiry  from  patients, 
he  must  have  certain  knowledge  of  the  subject  and  be  prepared  with  proper 
answers.  While  upon  questions  of  prognosis  it  is  not  well  to  make  definite 
statements  directly  to  the  patient — on  account  of  the  psychic  element,  with 


324         OCCUPATIONAL    AFFECTIONS    OF    THE    NOSE,    MOUTH,    ETC. 

dangers  of  loss  of  the  patient  or  his  suicide  from  unfavorable  prognosis — 
the  family  physician  and  the  family  should  be  made  fully  conversant. 
There  are  certain  lesions  of  the  eye  which  almost  invariably  result  in  loss 
of  function  and  even  in  loss  of  the  eyeball  itself;  for  instance,  ulcera- 
tions of  the  cornea  are  as  a  rule  followed  by  opacities,  varying  from 
nebulae  to  leucomata,  which  materially  diminish  the  visual  acuity,  es- 
pecially if  these  be  in  the  visual  axis.  Likewise,  lesions  complicated  with 
iritis  may,  if  not  properly  treated,  result  in  occlusion  of  the  pupil.  Injuries 
of  the  lens  almost  invariably  result  in  total  opacity,  although  there  have 
been  a  number  of  cases  observed  and  reported  in  which  foreign  bodies  have 
remained  in  situ  for  a  number  of  years  without  causing  further  opacity;  and 
development  of  partial  cataract  is  observed  in  many  cases.  To  this  we 
refer  to  cataract  from  electricity  and  distinguish  true  contusion  of  the  lens. 

Contusions  and  wounds  of  the  ciliary  region  frequently  result  in  chronic 
irido-cyclitis  and  atrophy  of  the  bulb.  Retained  foreign  bodies  in  the 
eye  result  in  bhndness  from  such  causes,  as  well  as  from  sympathetic 
ophthalmitis. 

Many  cases  of  amaurosis  follow,  as  is  well  known,  a  blow  on  the  head, 
of  which  the  pathogeny  is  an  indirect  fracture  through  the  optic  canal,  or 
an  effusion  of  blood  in  the  nerve  sheath.  But  more  frequently  is  it  the  case 
that,  following  a  trauma  of  the  cranium,  the  injured  person,  in  good  faith 
or  not,  claims  the  visual  loss  to  be  due  to  the  injury,  while  the  lessened  vision 
may  have  existed  prior  to  the  accident.  Of  course,  when  the  case  is  seen  just 
after  the  trauma  and  amaurosis  exists  it  is  impossible,  before  some  days 
have  elapsed,  to  discover  any  optic  nerve  change.  Optic  nerve  atrophy  will 
follow  in  a  short  time.  The  optic  papilla  will  guide  in  these  cases.  When 
the  case  is  seen  long  after  the  accident,  while  the  etiology  is  determined  with 
less  certainty,  nevertheless  to  the  trauma  of  the  cranium  may  be  attributed 
the  cause  if  the  contour  of  the  atrophied  papilla  is  clear. 

Precaution  and  attention  to  apparently  trivial  details  of  treatment  would 
curtail  in  a  marked  degree  the  number  and  success  of  personal  injury  suits. 

CONSERVATION  OF  THE  WOUNDED  EYE 

The  handling  of  an  injured  eye  should  be  conservative  from  the  first, 
to  keep  vision,  preserve  the  appearance,  relieve  the  agony,  and  even  in  some 
cases  to  save  life. 

The  public  should  be  taught  that  the  best  first  aid  to  injured  eyes  is,  as 
a  rule,  to  let  them  alone,  apply  clean  cloth  bandage  and  to  immediately  seek 
a  physician,  more  especially  an  oculist,  except  where  large  quantities  of 
foreign  material  as  sand,  dirt  or  corrosive  substances,  as  lime  or  chemicals, 
enter  the  eye;  then  the  first  application  is  free  douching  with  clean,  clear 
water. 

The  radical  treatment  of  injuries  to  the  eye  is  practically  summed  up  in 
the  word  enucleation,  nearly  all  other  procedures  being  conservative. 


OCCUPATIONAL    INJURIES    AND   DISEASES    OF    THE    EYE  325 

The  therapy  of  the  wounded  eye  is  based  upon  general  surgical  principles, 
and  from  beginning  to  end  the  watchword  is  asepsis,  or  cleanliness. 

Concerning  the  septicity  of  the  wound,  all  chips  of  metal  entering  an 
eye  may  be  considered  as  free  from  organisms,  the  septic  inflammations  being 
produced  by  the  subsequent  entry  of  organisms  either  through  the  tract  of 
the  wound  or  during  the  operation  for  removal. 

It  is  universally  recognized  that  when  the  foreign  body  is  in  the  anterior 
segment  of  the  eye,  the  injury  is  much  less  serious  than  when  it  has  passed 
on  through  the  lens  into  the  posterior  segment  or  has  entered  the  vitreous 
chamber  through  the  ciliary  region  or  the  sclera. 

A  different  story  of  the  dangers,  damages  and  results  must  be  told  about 
foreign  bodies  in  the  posterior  segment  of  the  eye,  for  as  a  rule  these  have 
flown  with  much  force,  have  already  wounded  the  anterior  structure  in  their 
course,  and  if  allowed  to  remain  in  the  eye  not  only  destroy  the  sight  and 
cause  atrophy  of  the  globe,  but  may  result  in  sympathetic  ophthalmitis. 

For  the  technical  treatment  of  injuries  to  the  eye  the  reader  is  referred  to 
the  text-books  on  ocular  therapeutics. 

II.  DISEASES  DUE  TO  OCCUPATION  INCURRING  EXCESSIVE  EYE 

STRAIN 

The  second  group  consists  of  neuropathies,  as  nystagmus  of  miners, 
spasms  of  the  orbicularis  of  watchmakers,  of  the  ocular  muscles  from  mili- 
tary drilling,  and  to  the  production  of  eye  strain  from  the  close  study  of  stu- 
dents and  in  occupations  requiring  prolonged  use  of  the  eyes. 

But  few  oculists  see  the  typical  nystagmus  of  miners,  but  to  those  who 
live  in  coal-mining  districts  as  well  as  to  the  workmen  and  employers  this 
subject  is  of  great  importance.  This  is  due  to  the  constrained  position  of  the 
workers,  either  in  excavating  the  coal  or  in  inspectors  from  tapping  the  roof 
to  see  if  it  is  safe. 

The  movements  of  the  eyes  are  mostly  rotatory,  occasionally  to  and  fro, 
but  seldom  vertical.  The  oscillations  may  be  stopped  by  turning  the  eyes 
downward.  Five  to  20  per  cent,  of  miners  suffer  and  have  to  quit  the  occu- 
pation for  intervals  or  altogether. 

Nystagmus  is  also  met  in  engravers,  draughtsmen  and  compositors, 
jewelers  and  typists,  but  is  only  incidental.  It  is  similar  in  type  to  writers' 
cramp  and  is  speedily  relieved  by  rest. 

Now  we  come  to  the  great  subject  of  eye  strain  from  muscular  and  re- 
fractive defects,  to  which  perhaps  90  per  cent,  of  civilized  eyes  are  subject, 
and  which  is  brought  on  by  close  use  of  the  eyes  and  is  relieved  by  lenses  and 
ocular  muscle  operations,  and  not  to  be  elaborated  here  as  thousands  of  pages 
of  print  on  this  subject  may  be  found  in  text-books  and  medical  magazines. 
It  must  be  remembered  that  perfectly  normal  as  well  as  diseased  eyes  may 
suffer  from  glare  and  eye  strain  from  overwork. 

The  production  of  myopia  in  schools  and  by  close  work  is  a  live  issue. 


326         OCCUPATIONAL   AFFECTIONS    OF    THE   NOSE,    MOUTH,    ETC. 

Certain  races  as  the  Teutons  and  the  Jews  seem  more  apt  to  develop  this 
anomaly,  which  in  some  leads  to  grave  changes  in  the  eyes  and  loss  of  visual 
acuity  or  even  blindness;  for  this  see  other  text-books. 

III.  DISEASES  DUE  TO   EXCESSIVE  EXPOSURE  TO   LIGHT  AND 

HEAT 

The  constant  gazing  at  bright  objects,  as  by  dentists  in  gold  filling  and 
by  electroplaters,  may  cause  evanescent  scotomata  which,  though  alarm- 
ing at  the  time,  disappear  on  resting  and  may  be  prevented  by  the  use  of 
appropriately  tinted  glasses. 

A  more  severe  affection  may  be  seen  in  steel  melters,  electro-welders, 
glass  workers  and  furnace  men  and  in  exposure  to  strong  light,  when  the 
brighter  light  may  not  only  temporarily  use  up  the  visual  purple  but  cause  a 
degeneration  of  the  retina  at  the  macula  similar  in  type  to  that  caused  by 
looking  at  the  sun  in  a  solar  eclipse.  Cobalt  and  dark  glasses  may  prevent 
the  occurrence. 

The  heat  of  melted  iron,  glass,  electric  and  other  furnaces,  etc.,  is  respon- 
sible for  burning  of  the  lids,  cornea  and  perhaps  even  for  the  cataract  of  glass 
blowers  and  degeneration  of  the  retina.  Protection  by  dark  glasses  and  hel- 
mets prevents  this  occurrence. 

Short  circuiting  of  electric  wires  give  rise  to  terribleigeneral  burns,  and 
the  electrolysis  to  formation  of  cataract  and  changes  in  the  retina,  amblyopia 
and  blindness.  Most  of  these  accidents  are  due  to  carelessness  of  employees 
and  are  to  be  prevented  only  by  education  and  intelligence. 

IV.  TOXICOLOGY— SYSTEMIC    POISONING    CAUSING   LOSS    OF 

SIGHT 

The  ingestion,  inhalation,  epidermic,  hypodermic,  endermic,  intra- 
muscular or  any  other  method  by  which  certain  toxic  substances  may  get 
into,  or  be  developed  within,  the  system  induces  changes  in  the  tissues  of  the 
eye  by  which  diverse  efifects  are  produced,  denominated  by  the  term  toxic 
amblyopia. 

Among  the  commonest  poisons  thus  affecting  the  eye  are  alcohol,  tobacco, 
iodoform,  naphthalin,  caffeine,  acetanilide,  salicylic  acid,  atoxyl,  arsenic,  felix 
mas,  santonin,  and  pomegranate,  to  which  some  persons  have  an  idiosyn- 
crasy, particularly  as  regards  damage  to  vision  and  the  eyes,  even  in  medici- 
nal doses. 

Arsenic  is  extensively  used  in  wall  paper,  clothing,  artificial  flowers, 
making  Paris  green  and  in  paints,  and  these  workers,  as  well  as  those  who 
take  it  medicinally  or  use  cosmetics,  are  liable  to  suffer  from  eczema  of  lids 
and  conjunctival  hyperaemia  as  well  as  in  a  few  cases  from  amblyopia  and 
optic  neurits. 

Of  those  occurring  in  trades,  there  have  been  reported  cases  of  miners' 


OCCUPATIONAL   INJURIES   AND   DISEASES    OF   THE   EYE  327 

arsenical  poisoning  with  resultant  optic  nerve  atrophy,  following  the  dust  from 
the  brittle  mineral  known  as  sulf arsenide  of  cobalt;  but  as  arsenic  is  usually- 
found  in  the  form  of  arsenical  pyrites  it  does  not  seem  to  cause  any  injurious 
effects. 

Likewise  in  ordinary  lead  mines  lead  poisoning  is  almost  unknown, 
as  it  is  usually  mined  in  the  form  of  galena,  the  sulphate  of  lead,  a 
heavy  and  quite  insoluble  substance.  In  carbonate  mines,  the  earthy  lead 
carbonates  give  rise  to  lead  poisoning,  and  in  a  few  cases  paralysis  of  the 
extrinsic  muscles  of  the  eye  has  been  noted.  In  the  production  of  the  white 
oxides  of  lead  for  paint,  plumbism  has  been  often  seen,  and  with  the  general 
symptoms  paralysis  of  the  ocular  muscles  has  been  noted.  Lead  is  used  in 
many  occupations,  especially  painting,  plumbing,  file  cutting.  No  acute 
eye  cases  are  reported,  but  chronic  cases  from  inhalation  and  wetting  of 
fingers,  holding  of  paint  brushes  and  tools  in  the  mouth,  central  and  peripheral 
contractions  of  the  visual  field  are  seen  from  retrobulbar  neuritis;  palsy 
of  the  eye  muscles  is  also  encountered. 

Amyl  alcohol  or  fusel  oil,  found  in  impure  wines,  whiskies,  etc.,  seldom 
causes  complete  blindness  and  is  rarely  known  in  trades,  generally  following 
chronic  alcoholism  usually  associated  with  tobacco. 

It  may  be  that  cases  have  occurred  of  tobacco  blindness  in  producers 
and  handlers  of  tobacco  from  inhalation  of  the  dust  or  from  licking  the  leaves 
as  is  sometimes  the  filthy  habit  of  cigar  makers,  but  I  have  never  seen  such. 
Those  tobacco  workers  that  I  have  encountered  with  toxic  amblyopia  were  all 
heavy  drinkers. 

Methyl  alcohol  or  wood  spirit  is  frequently  used  in  the  preparation  of 
varnish,  lacquer,  polish,  perfumes  and  other  industries  enumerated  in  the 
list  of  industrial  poisons  (see  page  73 1).  Cases  of  conjunctivitis,  also  serious 
affections  of  the  retina  and  the  optic  nerve  resulting  even  in  blindness  from 
atrophy  of  this  nerve,  have  been  reported. 

Tea  tasters  consume  an  enormous  amount  of  the  tea  and  I  have  seen 
several  cases  of  amblyopia  in  these  people,  who  have  all  recovered  when  they 
have  taken  a  vacation  from  their  vocation  together  with  appropriate  treat- 
ment. 

Bisulphide  of  carbon  in  rubber  making  has  been  shown  to  produce 
amblyopia.     It  is  less  used  than  formerly  in  curing  rubber. 

In  the  manufacture  of  explosives,  dinitrobenzol  is  responsible  for  gen- 
eral changes  in  the  blood  and  nervous  system  and  in  the  making  as  well 
as  the  using  of  same  for  explosive  charges,  especially  in  mines,  has  given  rise 
to  toxic  amblyopia. 

In  dye  factories  and  in  the  manufacture  of  coal-tar  products  there  are 
complaints  of  irritation  of  the  eyes  and  loss  of  vision  from  its  inhalation  and 
absorption,  possibly  due  to  aniline  poison. 

Iodoform  is  used  in  surgery  and  has  caused  kidney  and  eye  lesions,  but  no 
evil  effect  has  been  reported  from  its  manufacture. 


328         OCCUPATIONAL   AFFECTIONS    OF    THE    NOSE,    MOUTH,    ETC. 

THE  ESTIMATION  OF  ECONOMIC  DAMAGE 

Upon  the  use  of  the  organ  of  vision  depends  the  earning  powers  for  the 
large  majority  of  trades  and  professions;  thus  earning  ability  is  economically 
synonymous  with  visual  earning  ability. 

It  is  self-evident  that  a  totally  blind  person  is  absolutely  incompetent 
in  any  trade  or  profession  requiring  eyesight.  An  economically  blind 
person — i.e.,  one  whose  visual  acuity  is  less  than  5  per  cent,  of  the  normal — 
is  in  the  same  position,  for,  although  he  may  be  able  to  get  about,  the  vision 
is  not  sufficient  to  allow  of  even  the  lowest  grade  of  remunerative  work. 
The  vast  majority  of  blind  people  are  not  only  incapable  of  earning  anything, 
but  are  a  charge  upon  their  families  and  upon  the  community.  It  is  true 
that  there  are  certain  exceptions  to  the  above  proposition.  There  are,  and 
have  been,  blind  persons  who  have  become  poets,  machinists,  chair  makers, 
broom  makers,  etc.,  but  cases  that  have  become  economic  factors  are  so 
unusual  as  to  be  commented  upon  in  the  public  press  and  held  up  as  especially 
talented  and  well-placed  persons  who,  by  great  labor  of  their  teachers,  and 
by  their  own  exceptional  diHgence,  have  been  so  highly  educated  as  to  be 
able  to  meet,  in  a  measure,  with  the  competition  of  normal  individuals.  In 
the  case  of  an  adult  suddenly  becoming  blind,  his  previous  economic  educa- 
tion goes  for  naught,  and  he  at  once  steps  out  of  the  ranks  of  workers. 

Nearly  all  trades  and  professions  require  good  eyesight,  even  the  coarsest 
sort  of  labor  being  affected  if  the  vision  falls  below  50  per  cent.,  and  being 
impossible  if  it  is  below  0.05  per  cent,  of  the  normal  visual  acuity.  For 
finer  kinds  of  work,  the  visual  range  is  between  75  per  cent,  and  15  per  cent. 
A  workingman  who  either  suddenly  or  gradually  becomes  blind  loses  his 
job,  and  with  it  his  earning  ability.  Aside  from  the  loss  of  time  and  wages 
ensuant  upon  the  injury  and  convalescence  therefrom,  poor  sight  certainly 
affects  the  amount  and  character  of  work,  the  quality  and  output  diminishing 
in  a  direct  ratio  to  the  loss  of  sight,  until  a  degree  is  reached  where  the  person 
cannot  work  any  more.  The  remuneration  for  work  necessarily  depends 
upon  its  amount  and  its  quality.  Thus  injury  to  vision  generally  necessi- 
tates loss  of  earning  powers. 

The  pecuniary  value  of  a  man's  life  may,  for  our  purposes,  be  expressed 
by  the  amount  of  money  that  he  may  earn  in  the  course  of  his  life.  We  stated 
above  that  the  visual  earning  ability  was  economically  synonymous  with  the 
full  earning  abihty,  and  we  may  thus  value  vision  with  the  pecuniary  valua- 
tion of  life. 

We  may  say  that  "sight  is  priceless"  and  "vision  is  not  a  commodity 
that  may  be  purchased  or  disposed  of  in  the  market,"  for  there  are  few  per- 
sons who  would  voluntarily  allow  of  the  infliction  of  any  unnecessary  bodily 
injury  for  any  compensation  whatever;  but  such  matters  of  ethics  do  not  fall 
within  the  pale  of  our  present  discussion.  We  are  deahng  with  the  estab- 
lished economic  fact  that  injury  to  vision  of  more  than  a  certain  extent  neces- 


OCCUPATIONAL   I^7URIES    AND    DISEASES    OF    THE    EYE  329 

sitates  limitation  of  the  amount  and  character  of  work.  Following  upon 
this,  it  is  easily  deduced  that  the  amount  of  wages  received  would  be  less. 

The  question  now  arises,  how  are  we  to  reckon  the  loss  of  wages?  This 
we  may  do  from  experience  in  examining  large  numbers  of  individuals.  It 
has  been  found  that  the  loss  of  vision  of  a  certain  amount  results  in  a  certain 
effect  upon  the  earning  ability  of  the  individual.  We  may  also  deal  with 
futurities,  and  figure  the  probable  loss  in  any  given  case  by  finding  the  per- 
centage of  damage  to  the  normal  function,  and  apply  our  reasoning  to  the 
calculation  of  the  probable  pecuniary  loss.  In  order  to  do  this  we  have 
accepted  the  visual  earning  power  as  equivalent  to  the  total  earning  power. 

The  Formula  of  Magnus. — Magnus  therefore  evolved  a  formula  which  we 
have  accepted  as  the  simplest  and  most  appropriate,  which  considers  the 
visual  earning  ability  as  composed  of  the  several  factors  entering  onto  vision 
together  with  the  ability  to  compete,  expressed  as  an  arithmetic  equation. 

Thus: 

E  =  F^K. 

E  =  Earning  ability  =  ocular  earning  ability. 

F  =  Visual  act. 

■\/K  =  Ability  to  compete. 

F  =  C  (maximum) -s/p-v/lf  =  physiologic  act  of  vision  in  which 

C  (maximum)  =  maximum  acuity  of  the  better  eye. 

■y/p  =  Binocular  visual  field. 

\/M  =  -y/M  =  normal  value  of  ocular  muscles. 

This  is  modified  by  the  ability  to  compete: 

C   -\-  C  — 

in  which =  the  added  acuities  of  both  eyes,  -y/P  the  visual  field, 

and  \^M  the  muscular  action,  the  complete  formula  for  the  ocular  earning 
ability  being 

£  =  C  (maximum)  VpVM-^^'  "^  ^WpVm 

which  is  the  mathematical  expression  of  the  earning  ability  and  which  may  be 
readily  calculated  by  anyone  who  can  do  a  simple  algebraic  equation,  as  it  is 
reduced  to  a  simple  multiplication  example  by  using  tables  which  have  been 
compiled  for  the  purpose,  as  the  algebraic  signs  are  replaced  by  figures  which 
are  readily  found  therein.  The  roots  are  readily  calculated  or  may  be  found 
in  our  tables.  Wiirdemann  has  added  monetary  computation  to  this  for- 
mula and  the  method  is  now  known  and  accepted  as  a  scientific  fact  and  is 
received  as  such  in  present  forensic  practice.  (Visual  Economics,  Magnus 
and  Wiirdemann,  1902,  and  subsequent  essays.) 

Resume. — i.  The  former  usages  for  the  estimation  of  pensions,  insurance, 


330    OCCUPATIONAL  AFFECTIONS  OF  THE  NOSE,  MOUTH,  ETC. 

and  damages  at  law,  from  injury  to  vision,  are  based  wholly  upon  precedent 
and  are  purely  empirical. 

2.  The  relation  of  the  visual  act  to  the  earning  ability  is  susceptible  of 
mathematic  demonstration. 

3.  The  probable  loss  of  wa.ges—i.e.,  the  effect  on  the  earning  ability  of  the 
individual — may  be  determined  by  the  particular  injury  to  vision. 

4.  (a)  Insurance  contracts  will  probably  be  continued  under  the  present 
business  arrangements,  but  may  be  made  equitable,  subject  to  the  amount  of 
economic  damage,  a  percentage  of  the  sum  for  total  disability  being  paid  for 
partial  losses.  In  the  case  of  loss  of  vision  of  one  eye  the  rates  should  be 
modified  to  between  18  and  30  per  cent,  of  the  total  disability. 

(b)  For  the  settlement  of  pensions  and  annuities  the  full  annual  economic 
damage  should  be  paid. 

(c)  For  the  settlement  of  claims  at  law  the  probable  economic  damage 
should  be  estimated  and  considered  the  principal  element,  subject  to  business 
discount,  to  additions  for  the  actual  expenses  consequent  on  the  accident  and 
empirical  amounts  for  the  pain  and  anguish  thereto  incurred,  contributory 
negligence  and  other  legal  factors  being  also  considered  in  the  verdict. 

5.  The  calculations  and  rules  of  Magnus  and  Wiirdemann  afford  a  method 
of  estimating  the  amount  of  the  probable  economic  damage  in  a  manner  fair 
and  just  to  all  parties  and  agreeable  to  all  legal  demands. 


CHAPTER  II 
GLASS -WORKERS'  CATARACT 

BY  T.  M.  LEGGE,  M.  D.,  London,  England. 

Following  on  the  Workmen's  Compensation  Act,  1906  which,  in  section  8, 
applied  the  principle  of  compensation  as  in  the  case  of  accidents  to  poisoning 
by  lead,  arsenic,  phosphorus,  and  mercury,  and  to  the  two  infections  by  an- 
thrax and  ankylostomiasis,  a  Committee  was  appointed  to  consider  what 
other  diseases  were  due  to  industrial  occupation,  were  distinguishable  as 
such,  and  could  properly  be  brought  under  the  provisions  of  the  section. 
One  of  the  most  interesting  diseases  thus  brought  under  review,  and  the  one 
upon  which  there  was  the  greatest  difficulty  in  coming  to  a  decision,  was  occur- 
rence of  cataract  in  glass  workers.  In  regard  to  the  disease  four  questions 
had  to  be  decided:  (i)  Did.it  exist?  (2)  Was  it  much  more  frequent  in 
glass  workers  than  in  the  general  male  population?  (3)  Was  it  characteris- 
tic? (4)  Would  it  be  in  the  interests  of  the  workers  themselves  to  schedule 
it  since  not  the  fact  of  having  cataract  entitled  to  compensation  but  only 
incapacity  resulting  from  it? 

The  attention  of  the  Committee  was  first  directed  to  the  subject  by  the 
evidence  of  the  secretary  of  the  glass-bottle  makers  of  Yorkshire  United 
Trade  Protection  Society — a  signal  instance  of  the  value  of  the  material 
contained  in  such  Society  records  if  only  they  are  properly  used.  He  suffered 
from  defective  eyesight  himself  and  in  noting  the  sickness  claims  was  struck 
by  the  frequency  with  which  cataract  appeared  as  a  cause  leading  to  super- 
annuation. Thus  he  was  able  to  show  that  among  some  2000  members  of 
whom  114  were  superannuated,  no  less  than  34  (30.0  per  cent.)  had  suffered 
or  were  suffering  from  cataract.  In  another  similar  trade  society  with  1000 
members  it  was  ascertained  that  6  out  of  30  members  on  the  superannuation 
fund  were  disabled  on  account  of  cataract. 

The  employers,  on  the  other  hand,  attached  small  importance  to  the 
ailment  no  doubt  because  the  number  of  cases  in  proportion  to  the  number 
of  men  employed  was  small  and,  in  individual  works,  so  extremely  small  as 
to  make  some  of  them  deny  its  existence  as  a  trade  disease.  The  matter, 
from  the  administrative  point  of  view,  was  further  seriously  complicated  by 
the  fact  that  employers  threatened  in  self-defence,  if  glass  workers'  cataract 
were  scheduled,  to  have  periodical  examination  of  the  eyes  of  the  persons 
employed  made  and  to  discharge,  many  years  it  might  be  before  there  was 
any  incapacity,  those  showing  changes  in  the  lens.  Nor  did  the  Committee 
at  the  time  they  had  to  report  know  of  any  statistics  showing  what  the  inci- 
dence of  cataract  was  among  the  general  population.     If  cataract,  they  said, 

331 


332  OCCUPATIONAL   AFFECTIONS    OF    THE    NOSE,    MOUTH,    ETC. 

was  found  to  be  lo  times  as  frequent  in  glass  workers  as  among  other  people 
of  similar  age  the  disease  ought  to  be  scheduled,  even  although  in  one  case 
out  of  ten  the  employer  would  be  required  to  pay  compensation  to  a  man 
in  whom  it  would  have  developed  had  he  never  been  employed  in  that  trade. 
The  matter,  therefore,  was  left  over  for  further  inquiry  which  I  was  asked 
to  make. 

Already,  in  1903,  Dr.  W.  Robinson,  Surgeon  to  the  Sunderland  and  Dur- 
ham County  Eye  Infirmary — a  district  comprising  several  bottle  and  pressed 
glass  works — had  published  a  paper  in  which  he  concluded  that  hard  cataract 
in  bottle  finishers  was  very  common.  "How  much  commoner  it  is  than 
among  the  rest  of  the  community  is  shown  by  the  fact  that  18  out  of  75 
(i  in  4)  hard  cataracts  operated  on  last  year  in  our  Eye  Infirmary  were  in 
bottle  finishers,  there  being  only  200  or  300  bottle  finishers  in  a  population 
of  nearly  a  million  and  a  quarter  in  this  county." 

Briefly  described  the  work  in  a  glass-bottle  factory  is  as  follows:  The 
mixed  materials  spoken  of  as  "metal"  and  consisting  of  sand,  clay,  lime, 
marl,  etc.,  are  thrown  by  the  "founder"  into  a  furnace  or  "tank"  kept  at 
a  white  heat  of  about  i5oo°C.  At  the  opposite  end  of  the  furnace  are 
several  openings  at  which  the  bottle  makers  work  in  squads  of  five  each. 
The  "gatherer"  dips  the  iron  blowpipe  into  the  metal,  having  in  doing  so 
naturally  to  look  into  the  white  mass,  and  takes  up  sufficient  to  make  a  bottle. 
This  he  hands  to  the  bottle  blower  who  places  it  in  a  mould  and  blows  down 
the  pipe  to  form  the  bottle.  From  the  glass  blower  the  bottle,  still  on  the 
end  of  the  pipe,  is  handed  to  the  finisher  who  cuts  it  ofif  from  the  pipe.  The 
finisher,  standing  right  up  against  the  "gloriole,"  looks  through  this  into  the 
molten  metal  and  takes  up  sufficient  to  form  the  rim  on  the  neck  of  the  bottle. 
He  then  seats  himself,  sheltered  by  a  brick  projection,  and  puts  the  rim  on 
round  the  neck. 

Robinson  calculated  that  during  each  shift  of  11  hours  from  no  to  120 
bottles  are  finished,  and  reckoning  the  time  of  looking  into  the  furnace  at 
about  3  seconds  a  time,  the  eyes  of  the  finisher  are  exposed  to  the  glare  for 
5)^  hours  a  week. 

In  the  making  of  pressed  and  flint  glass  the  heat  is  not  so  intense  and 
the  finisher  of  flint  glass  bottles  sits  some  yards  away  from  the  furnace  into 
which  he  need  never  look.  The  processes  in  the  manufacture  of  sheet  and 
plate  glass  are  essentially  the  same.  Sheet  glass,  however,  in  the  present 
day  is  blown  not  by  the  mouth  but  by  means  of  compressed  air  into  huge 
cylinders  which  are  first  annealed  and  then  cut  into  two  halves  and  flattened 
out  in  a  furnace  kept  at  a  dull  red  heat  only. 

As  to  the  character  of  the  cataract,  Robinson  pointed  out  in  proof  of  its 
industrial  origin  from  exposure  to  the  intense  heat  and  light  of  the  furnace 
that  it  commenced  always  at  the  posterior  pole  of  the  lens  involving  the  cortex. 
Ordinary  senile  cataract  on  the  other  hand  developes  usually  in  the  form  of 
sectors  or  radii  from  the  periphery  of  the  lens.     His  explanation  of  its  origin 


glass-workers'  cataract 


S33 


was  that  the  posterior  pole  was  practically  the  optical  center  where  the  prin- 
cipal rays  falling  on  the  lens  cross  and  pass  on  without  refraction,  and  further, 
the  point  where  undue  crowding  together  of  all  the  rays  from  the  furnace, 
except  the  direct  and  principal,  rays  which  undergo  refraction  at  the  anterior 
surface    of    the   lens. 

In  a  subsequent  paper  in  1907  Robinson  adduced  as  further  evidence  of 
his  contention  the  results  of  his  examination  of  the  men  in  three  glass  works 
in  the  Sunderland  district  where  among  aoo  men  he  found  37  finishers  and 
3  gatherers  who  were  sufifering  from  cataract. 


Table  i. — Changes  in  the  Lens  among  513  Men  Engaged  in  the  Gathering,  Blowing, 
Finishing,  and  Flattening  of  Glass,  and  278  Other  Persons,  All  30  Years 

OF  Age  and  Over 


Occupation 

30-40 

Per- 
cent- 
age 

41-S0 

i    Per- 
cent- 
age 

,51-60 

!    Per- 
1   cent- 
age 

Ovei 
60 

Total 

Per- 
cent- 
age 

Sheet  glass — 

Blowers 

48 

5 
90 

7 
78 
12 

10.4 

7.8 

15-4 

19 

2 

23 
4 

20.0 
10.5 
17.4 

2 

2 
2 
2 
2 

33-3 

I 
I 

61 

8 

III 

II 
103 

18 

Positive 

13    I 

Gatherers 

Positive 

100. 0 

9-9 

Flatteners 

Positive 

100. 0 

17-5 

Total 

216 
24 

II. I 

52 
8 

iS-4 

6 

4 

71.4 

I 
I 

275 
37 

Positive 

13-5 

Glass  bottles — 

Finishers 

88 
7 
9 

7-9 

68 

14 

I 

20.6 

32 
16 

S 

2 

I 

52.8 
SCO 

4 
3 
3 
2 

192 

40 

18 

4 

9 

3 

Positive 

20  8 

Blowers 

Positive 

Gatherers 

5 
2 

40.0 

3 

I 

33-3 

Positive 

33-3 

Total 

102 

9 

8.8 

72 
15 

20.8 

38 

18 

5I-I 

7 

5 

219 
47 

Positive 

21. 5 

Pressed  glass — 

Finishers 

7 
I 

4 

I 

14-3 

3 

4 

3 

80.0 

I 
I 

IS 
5 
4 

I 

Positive 

33-3 

Gatherers 

Positive 

25.0 

25.0 

Total 

II 
2 

18.2 

3 

4 
3 

80.0 

I 

I 

19 
6 

Positive 

31.6 

Grand  total 

329 
35 

10.6 

127 
23 

18. 1 

48 
25 

56.1 

9 

7 

513 
90 

Positive 

17-5 

Other  persons 

141 
3 

2.1 

90 
8 

8.9 

45 
8 

17.0 

2 

278 
19 

Positive 

6  8 

334    OCCUPATIONAL  AFFECTIONS  OF  THE  NOSE,  MOUTH,  ETC. 

Comparative  data,  however,  were  wanting.  To  obtain  them  I  examined 
the  crystalhne  lens  in  the  eyes  of  513  glass  workers  engaged  in  the  gathering, 
blowing,  finishing  and  flattening  of  glass.  Subsequently,  under  precisely 
the  same  conditions,  I  examined  the  eyes  of  278  persons  who  were  not  glass 
workers. 

The  results  are  shown  in  Table  i. 

Viewed  in  this  way  changes  in  the  lens  are  shown  to  be  about  five  times  as 
frequent  in  glass  workers  between  30  and  40  years  of  age  as  in  other  persons, 
about  twice  as  frequent  in  those  between  41  and  50,  and  over  three  times  as 
frequent  in  those  over  50.  All  classes  of  workers  exposed  to  incandescent 
molten  glass  appeared  to  suffer,  and  the  differences  which  are  to  be  noted  in 
the  incidence  on  those  making  sheet  glass,  glass  bottles,  and  pressed  glass, 
are  not  striking.  A  point  of  interest  was  that  the  class  of  gatherers  in  sheet 
glass  works  showed  considerably  the  smallest  number  affected.  The  heat 
from  the  furnace  here  is  so  intense  that  the  gatherer  is  compelled  to  shield  his 
face  with  a  screen,  held  in  the  mouth,  with  blue  glass  in  front  of  the  eyes. 

Mere  statement  of  the  number  needs  to  be  ampUfied  by  character  of  the 
changes  observed.  The  very  striking  differences  thus  brought  out  can  be 
tabulated  as  follows: 


Comparison  of  the  Nature  of  the  Changes  in  the  Crystalline  Lens  of  the  513 
Glass  Workers  and  278  Other  Persons 


S13  glass 
workers 


Right  i  Left 


278  other 
persons 


Right     Left 


Cataract  extracted 

Cataract  so  mature  that  its  nature  could  not  be  determined.. 

Posterior  cortical  cataract 

Commencing  posterior  cortical  cataract 

Dot-like  posterior  cortical  opacity  (in  central  area) 

Posterior  cortical  opacities  (not  in  central  area),  radii,  striae. 

Peripheral  striffi,  radii  and  sectors 

Other  opacities 

General  dulness  of  lens 


3 

4 
17 
5 
5 
4 
14 
5 
7 


2 
^9 


IS 
3 
7 


I 

I 

I 
II 

I 



I 

9 

2 

Total '     64 


14       13 


When  viewed  with  the  ophthalmoscope  by  the  indirect  method  the  char- 
acteristic change  in  the  lens  of  the  glass  worker  is  opacity  of  the  posterior 
cortical  layers  (like  a  blot  of  ink)  of  varying  size,  within  the  pupillary  area. 
Changes  in  the  posterior  layers  were  present  indeed  in  over  half  the  positive 
cases.  In  the  control  population  examined  the  characteristic  change  was, 
as  one  would  have  expected,  the  appearance  of  peripheral  striae  around  the 
margin  of  the  lens,  the  central  pupillary  area  remaining  perfectly  clear. 
There  was  exception  to  this  in  two  cases  only  and  in  them  the  changes  could 


GLASS-WORKERS     CATARACT  335 

not  be  distinguished  from  the  condition  observed  in  glass  workers.  The  occu- 
pation of  one  of  these  had  been  constant  attendance  for  25  years  at  an  anneal- 
ing furnace  in  Woolwich  Arsenal — work  similar  to  that  of  a  glass  flattener. 
Among  the  control  population  none  had  sought  treatment  for  cataract,  and 
certainly  in  not  more  than  three  were  the  opacities  so  pronounced  as  to  cause 
any  impairment  of  sight.  Among  the  glass  workers,  however,  in  addition  to 
six  in  whom  a  single  extraction  for  cataract  had  been  performed  and  in  one  a 
double  extraction,  there  were  at  least  25  others  in  whom  the  sight  of  one  or 
other  of  the  eyes  was  seriously  impaired  by  the  opacity.  Yet  it  was  surpris- 
ing how  almost  unimpaired  for  work  the  sight  appeared  to  be  of  several  of 
those  in  whom  small  but  quite  definite  posterior  cortical  cataract  was  present. 
Even  when  vision  is  affected  the  bright  light  given  out  from  the  molten  glass 
and  the  mechanical  nature  of  the  work  both  help  to  overcome  or  mask  the 
defect.  Were  the  occupation  one  necessitating  fine  work  the  condition  would 
become  apparent  much  sooner.  Many,  no  doubt,  pass  through  the  normal 
working  life  ignorant  of  its  existence. 

I  next  sought  figures  as  to  cataract  as  a  cause  of  disablement  and  super- 
annuation in  other  trade  societies.  The  Hearts  of  Oak  Benefit  Society  with 
a  membership  of  some  300,000  had  a  large  class  receiving  reduced  sick 
allowance  the  conditions  of  receipt  of  which  were  that  the  member  should 
have  been  on  the  Society's  sick  funds  for  at  least  12  months.  I  beUeved 
that  if  the  number  of  those  in  receipt  of  this  reduced  sick  allowance  could  be 
ascertained  for  a  number  of  years  fair  comparison  was  possible  with  the 
figures  supplied  to  the  Committee  of  superannuated  members  by  various 
glass-bottle  Trade  Societies.  This  I  was  able  to  do,  finding  the  incidence  of 
cataract  among  the  10,549  members  in  receipt  of  reduced  sick  allowance  0.78 
per  cent,  as  compared  with  22.6  per  cent,  among  the  186  superannuated 
members  of  glass-bottle  Societies.  The  average  age  of  incapacity  from  cata- 
ract was  in  both  about  the  same — 56  years.  Cataract,  indeed,  as  a  cause  of 
disablement  among  superannuated  members  of  the  Yorkshire  Bottle  Makers' 
Society  considerably  exceeded  the  disablement  from  every  form  of  heart 
and  lung  disease  among  the  members  on  the  reduced  sick  allowance  of  the 
Hearts  of  Oak  Benefit  Society. 

While  the  case  was  thus  proved  for  the  industrial  origin  of  the  disease 
the  fact  remained  that  it  was  of  very  slow  growth,  and  that,  during  the  many 
years  when  the  efficiency  of  the  workman  remained  unimpaired,  it  would  be 
impossible  for  him  to  claim  compensation.  And  yet  an  ophthalmoscopic 
examination  of  the  eyes  would  reveal  the  disease  in  an  incipient  stage.  The 
scheduling  of  the  disease  without  quahfication  thus  opened  out  grave  ques- 
tions as  to  the  probable  effect  of  such  a  course  upon  the  prospects  of  the  men 
affected.  These  were  anxiously  considered  by  the  Committee  with  the 
result  that  a  half-way  course  was  recommended,  namely,  the  scheduling  of 
the  disease  but  with  compensation  restricted  to  cases  where  an  operation  was 
undergone  and  for  a  period  not  exceeding  6  months.     Thus  not  only  would 


336    OCCUPATIONAL  AFFECTIONS  OF  THE  NOSE,  MOUTH,  ETC. 

there  be  inducement  for  the  sufferer  to  submit  to  the  comparatively  safe 
operation  for  the  removal  of  cataract  after  which  usually  glass  workers  are 
able  to  obtain  employment  again — sometimes  even  at  the  highly  skilled  work 
of  finishing,  and  employers  also  would  not  deem  it  worth  the  while  to  incur 
the  expense  of  arranging  for  periodical  examination  or  hesitate  to  employ  a 
glass  worker  with  incipient  cataract  because  of  possible  compensation  to  him 
for  a  period  so  short  as  6  months. 

I  was  unable  to  say  whether  heat  rays  or  light  rays  caused  the  condition 
nor  could  I  suggest  an  efficient  remedy.  The  combined  knowledge  of  the 
physicist  and  physiologist,  I  said,  was  required  to  arrive  at  a  conclusion  on 
these  points.  This  side  of  the  question,  however,  was  taken  up  by  a  Com- 
mittee of  the  Royal  Society  among  whom  were  Sir  William  Crook's,  O.  M., 
F.  R.  S.  on  the  physical  side  and  Dr.  J.  Franklin  Parsons  on  the  physiological. 

The  former  directed  his  attention  to  the  effect  of  adding  various  metallic 
oxides  to  the  constituents  of  glass  in  order  to  cut  off  the  invisible  rays  at  the 
ultra-violet  and  the  infra-red  ends  of  the  spectrum,  i.e.,  to  cut  off  those  rays 
from  highly  heated  molten  glass  which  are  beHeved  to  damage  the  eyes  of 
workmen  without,  at  the  same  time,  obscuring  too  much  light.  X-rays  were 
not,  he  found,  emitted  by  the  highly  incandescent  molten  glass.  In  the 
radiation  from  molten  glass  Crookes  found  the  heat  rays  in  far  greater  abun- 
dance than  the  ultra-violet,  and  from  this  he  inferred  that  it  is  to  the  heat 
rays  rather  than  to  the  ultra-violet  that  glass  workers'  cataract  is  to  be  ascribed. 
It  is,  however,  certain,  he  adds,  that  exposure  to  excess  of  ultra-violet  light 
also  injuriously  affects  the  eye. 

By  means  of  extraordinarily  exact  scientific  experiments  with  apparatus 
devised  by  himself  and  with  different  glasses  made  by  himself  to  which 
known  quantities  of  pure  metalHc  oxides  and  earthy  salts  were  added,  Crookes 
determined  for  each  glass  so  prepared: 

1.  The  percentage  amount  of  infra-red  rays  absorbed. 

2.  The  percentage  amount  of  ultra-violet  rays  absorbed. 

3.  The  percentage  amount  of  luminous  rays  transmitted. 

To  be  generally  useful  a  glass  should  absorb  rays  of  longer  wave  length 
than  about  X  7200  and  so  cut  off  dark  heat  radiation  and  it  should  also  be 
opaque  to  wave  lengths  shorter  than  about  X  3550  thus  cutting  off  the  most 
chemically  active  rays. 

Finally  he  was  able  to  prepare  glasses  cutting  off  over  90  per  cent,  of  heat 
radiation,  opaque  to  the  invisible  ultra-violet  rays,  and  sufficiently  free  from 
color  to  be  scarcely  noticeable  when  used  as  spectacles.  All  three  desiderata, 
however,  could  not  be  combined  in  one  and  the  same  specimen.  The  glasses 
he  describes  ''include  specimens  suitable  for  spectacles  adapted  to  all  require- 
ments— from  eyes  of  youth  to  eyes  of  age."  He  gives  the  composition  of  the 
glasses  cutting  off  as  much  as  possible  of  the  heat  radiation.  Thus  in  one  of 
a  neutral  tint  cutting  off  94  per  cent.,  opaque  to  ultra-violet  rays  of  shorter 


glass-workers'  cataract  337 

wave  length  than  X  3610  and  allowing  30  per  cent,  of  incident  light  to  pass 
through,  the  composition  was  raw  soda  flux  88.5  per  cent.,  black  mica  11.5 
per  cent.;  of  another  enabling  the  worker  to  see  better  at  the  expense  of  a 
little  athermancy  the  proportions  were:  fused  soda  flux  88.47  P^r  cent., 
ferric  oxide  1.50  per  cent.,  cobalt  sulphate  crystallized  0.03  per  cent.,  and 
cerium  nitrate  10.00  per  cent.  This  is  of  a  pale  blue  and  transmits  63  per 
cent,  of  luminous  rays  while  cutting  off  51  per  cent,  of  the  heat  rays.  Spec- 
tacles of  this  glass,  he  says,  scarcely  appear  to  obstruct  light  at  all  and  the 
colors  of  the  objects  are  practically  unchanged. 

Selections  of  glasses  prepared  according  to  the  formulae  in  Sir  William 
Crookes's  paper  are  made  by  Messrs.  Chance  Brothers  and  Co.,  Ltd.,  near 
Birmingham,  and  at  the  Whitefriars  Glass  Works,  London,  E.  C. 

Glasses  such  as  these  may  prevent  the  incapacity  arising  from  glass- work- 
ers' cataract.  The  disease,  however,  is  so  slow  in  its  onset  that  prejudice 
against  wearing  anything  interfering  in  the  least  with  work  is  great  and  will 
have  to  be  overcome.  Few  glass  workers  to-day  are  found  attempting  to 
preserve  their  eyesight  by  spectacles,  partly  from  the  reason  stated,  and 
partly  because  moisture,  when  perspiration  is  excessive,  condenses  on  the 
glass.  The  latter  objection  can  be  overcome  by  rubbing  the  glasses  with  a 
"Lasin"  pencil  made  of  a  kind  of  soap. 

Another  and  very  powerful  cause  is  at  work  which  will  tend  not  only  to 
minimize  the  chance  of  occurrence  of  cataract,  but  also  of  another  occupa- 
tional disease,  which  has  occasionally  been  the  result  of  infection  from  com- 
mon use  of  the  same  blowpipe,  namely,  syphilis  among  glass-blowers.  To 
guard  against  syphilis  contracted  in  this  way  the  French  Government  has 
enacted  regulations  requiring  medical  examination  of  glass-blowers  at  fort- 
nightly intervals.  The  cause  to  which  I  refer  is  the  substitution  of  machinery 
for  hand-work  in  the  manufacture  of  glass  bottles.  A  machine  is  already 
installed  in  some  works — and  the  example  will  be  quickly  followed  elsewhere 
— which,  as  it  is  made  to  revolve  over  the  margin  of  the  molten  glass,  sucks 
up  just  the  necessary  amount,  then  transfers  the  glass  so  sucked  up  to  a  mould 
where  the  bottle  is  formed  by  compressed  air  automatically  supplied  to  it,  and 
finally  discharges  the  bottle  in  a  finished  condition  ready  to  be  annealed. 
The  machine  does  its  work  at  the  rate  of  40  bottles  a  minute  at  a  cost  for 
labor  for  the  three  men  needed  to  supervise  its  operations  about  one-ninth 
that  now  paid  for  the  same  number  of  bottles  manufactured  in  the  old  method 
involving  manipulation  by  40  men  and  boys.  At  present  the  machine 
cannot  make  every  kind  of  bottle.  It  cannot,  for  example,  introduce  the 
glass  marble  which  forms  the  stopper  in  the  popular  form  of  lemonade  bottle 
so  that  for  some  years  to  come  bottle  making  by  hand  must  continue.  The 
hard  conditions  in  glass  works  are  just  those  which  should  gradually  be 
replaced  by  machinery  and  how  effectively  the  new  machine  achieves  this 
must  be  seen  to  be  believed. 


338         OCCUPATIONAL   AFFECTIONS    OF    THE    NOSE,    MOUTH,    ETC. 

REFERENCES 

Bottle-finishers'  Cataract,  by  W.  Robinson,  M.  D.,  M.  S. — Brit.  Med.  Journ.,  1903. 

On  Bottle-makers'  Cataract,  by  W.  Robinson,  M.  D. — Brit.  Med.  Journ.,  1907. 

An  Inquiry  into  the  Alleged  Frequency  of  Cataract  in  Bottle  Makers,  by  Simeon  Snell — 

F.  R.  C.  S.— Edin.  Brit.  Med.  Journ.,  1907. 
Second  Report  of  the  Departmental  Committee  on  Compensation  for  Industrial  Diseases. 

Minutes  of  Evidence  and  Appendix,  1908.     (This  contains  the  papers  by  Robinson 

and  Snell.) 
Katarakt  bei  Glasblasern,  J.  Rohlinger. — Munich,  1888. 
Zur   Aetiologie  des    Grauen    Stars.     Jugendliche    Katarakten  bei   Glasmachern,  By   D. 

Meyhofer  in  Gorlitz. 
Klinische  Monatsblatter  fiir  Augenheilkunde,  i886,Vol.  XXIV,  page  49. 
On  the  Origin  and  Chemical  Peculiarities  of  Glass-blowers'  Cataract,  by  Sanitatsrat,  Dr. 

E.  Cramer  in  Kottbus.     Klinische  Montasblatter  fiir  Augenheilkunde,  1907. 

The  Preparation  of  Eye-preserving  Glass  for  Spectacles,  by  Sir  William  Crookes,  O.  M. 

F.  R.  S.— Phil.  Trans.,  Series  A,  Vol.  CXIV,  pages  1-25. 


CHAPTER  III 
OCCUPATIONAL  INJURIES  AND  DISEASES  OF  THE  EAR 

BY  CLARENCE  JOHN  BLAKE.  M.  D..  Boston,  Mass. 

Injuries  and  diseases  of  the  ear,  of  occupational  origin,  may  be  grossly 
divided  into  three  classes;  those  which  are  limited  to  the  external  ear,  those 
which  affect  the  sound-transmitting  apparatus  of  the  middle  ear,  and  those 
which  are  ultimately  expended  in  their  deleterious  effect  upon  the  more  deli- 
cate sound-transmitting  apparatus  of  the  cochlea  and  the  terminal  nerve 
distributions  which  constitute  the  static  organ  of  the  labyrinth. 

Of  these  three  classes  the  latter  two  are  more  likely  to  have  an  intermedi- 
ate ground  of  relationship,  in  so  far  as  major  disturbances  are  concerned, 
disruptive  injuries  to  the  middle  ear  being  sometimes  associated,  in  their  con- 
sequences, with  disturbances  of  the  labyrinthine  mechanism  and  function  but 
labyrinthine  disturbances  incident  to  the  trades  stand  apart  by  themselves, 
the  middle-ear  implication  being  purely  secondary  to  the  deeper  seated  exci- 
tation or,  possibly,  part  of  a  natural  protective  process.  The  injuries  to  the 
ear,  of  occupational  origin,  may  range  from  a  solution  of  continuity  of  the 
auricle  incident  to  a  blow  to  the  structural  changes  induced  in  the  membran- 
ous cochlea  by  continued  exposure  to  loud  sounds. 

Standing  outward,  from  the  side  of  the  head,  to  which  it  is  attached  by 
three  groups  of  muscles,  in  addition  to  its  ligamentous  and  other  soft  tissue 
attachments,  composed  of  a  thin  plate  of  cartilage  covered  with  a  very  vascu- 
lar skin,  the  auricle  is  especially  subject  to  injury  in  such  trades  as  imply 
exposure  to  extremes  of  temperature,  and  to  possibilities  for  forcible  contact 
with  hard  substances. 

The  effect  upon  the  auricle  of  exposure  to  extreme  cold  in  the  indoor 
trades  is  less  frequently  observed  than  that  produced  by  climatic  exposure, 
but  the  results  are  the  same,  a  circumscribed  dermatitis,  sometimes  a  peri- 
chondritis with  resultant  thickening  and,  occasionally,  a  sero-sanguinolent 
effusion  beneath  the  skin,  on  the  anterior  surface  of  the  auricle,  with  conse- 
quent distortion  of  its  contour;  the  more  extreme  results  of  the  induced  in- 
flammation, necrosis  with  sloughing  and  loss  of  a  portion  of  the  auricle,  being 
less  frequent  in  the  indoor  trades — cold-storage  plants  for  instance — than  in 
cases  of  chmatic  exposure,  both  because  the  exposure  is  less  and  because  the 
subjection  to  it  is  more  under  individual  control. 

Similar  inflammatory  changes  in  the  auricle  are  the  result  of  exposure  to 
extreme  heat;  stokers,  smelters,  braziers,  puddlers  and  railway  firemen  are 
liable  to  circumscribed  inflammations  of  the  dermis  on  the  anterior,  the  more 

339 


340    OCCUPATIONAL  AFFECTIONS  OF  THE  NOSE,  MOUTH,  ETC. 

exposed  surface  of  the  auricle  and  especially  in  the  region  of  the  helix  and  the 
tragus,  while  the  dust  and  grime  accompanying  these  and  similar  occupations, 
including  metal,  glass,  stone  and  wood  workers,  using  denatured  alcohol,  and 
grinders  and  polishers,  mother-of-pearl  cutters,  brush  makers,  are  frequently 
productive  of  some  form  of  eczema  of  the  auricle  and  of  the  external  canal. 

In  all  of  the  trades  dealing  with  molten  metals  wounds  and  burns  of  the 
auricle  are  frequently  possible.  These  injuries  are  usually  circumscribed 
and,  unless  they  penetrate  to  and  involve  a  serious  solution  of  continuity  of 
the  cartilage,  are,  usually,  superficial  in  their  effects;  where,  however,  this 
solution  of  continuity  has  taken  place,  the  intrinsic  muscles  of  the  auricle 
exert,  by  their  contraction  against  lessened  resistance,  a  distorting  effect 
and  the  resultant  deformity  of  the  auricle  is  enhanced. 

In  the  major  injuries  of  the  auricle  the  three  bundles  of  extrinsic  muscles, 
attaching  and  supporting  the  auricle,  the  attollens,  attrahens  and  retrahens 
aurem,  have  to  be  taken  into  consideration,  for  under  conditions  in  which  the 
auricle  has  been  nearly  severed  from  its  ligamentous  and  minor  muscular 
attachments  together  with  division  of  its  mainly  supporting  muscular  bundles, 
the  attollens  and  retrahens  aurem,  it  is  necessary  in  effecting  surgically  re- 
apposition  of  the  wounded  parts  to  stitch  the  severed  muscles  as  well  as  the 
surrounding  soft  tissues  in  order  to  insure  the  lumen  of  the  reconstructed 
external  auditory  canal,  failure  to  resupply  this  muscular  support  of  the  auricle 
resulting  in  faulty  apposition  of  the  disrupted  cartilaginous  portion  of  the 
external  auditory  canal. 

Blows  upon  the  auricle  incident  to  the  trades  and  to  some  sports,  boxing 
and  football  for  example,  are  frequently  productive  of  othaematoma,  a  sub- 
dermal  or  subperichondrial  sero-sanguinolent  effusion  occurring  upon  the 
anterior  surface  of  the  auricle  to  the  obliteration  of  the  superior  fossae. 
Similar  effusions  of  lesser  extent  and  occurring  usually  in  the  concha  and 
lower  portion  of  the  auricle  are  the  result,  sometimes,  not  of  directly  applied 
violence  but  of  strain  in  the  lifting  of  heavy  weights  or  of  violent  exertion  as 
in  running,  the  occurrence  of  the  effusion  in  such  instances  usually  implying 
some  structural  weakness  in  the  cartilage  or  in  the  blood  supply  of  the  auricle. 

In  all  forms  of  othaematoma  the  thorough  evacuation  of  the  sac  cavity 
and  the  permanent  apposition  of  its  walls  are  necessary  to  avoidance  of  the 
disfiguring  distortion  of  the  auricle  evidenced  not  infrequently  to-day  as 
well  as  portrayed  in  the  busts  of  ancient  gladiators. 

Injuries  not  only  to  the  auricle  but  also  to  the  external  canal  and  even 
the  drum  head  are  not  infrequent  in  the  trades  which  have  to  deal  with  the 
fabrication  of  metals;  blacksmiths,  and  other  hammerers  and  forge  workers 
are  subject  to  injury  from  flying  particles  as  are  also  stone  masons  and,  less 
frequently,  wood  workers,  while  the  dust  resultant  in  these  and  similar  occu- 
pations settling  upon  the  auricle  and  about  the  entrance  of  the  external 
auditory  canal  and  requiring  vigorous  washing  for  its  removal  may  be,  in 
the  course  of  that  process,  washed  into  the  external  canal  and  there  retained 


OCCUPATIONAL   INJURIES   AND   DISEASES    OF    THE    EAR  341 

with  the  effect  not  only  of  obtunding  the  hearing  but  of  setting  up  irritation 
in  the  skin  Hning  the  canal.  In  this  latter  respect  the  character  and  consti- 
tution of  the  dust  has  a  determinative  effect,  the  dust  of  iron,  steel  and  of 
coal  having  usually  a  merely  obstructive  effect,  while  that  of  zinc  ore,  con- 
taining also  lead,  cadmium  and  arsenic,  is  more  or  less  irritating  and  conse- 
quently productive  of  eczema  of  the  auricle  and  canal  and  of  furunculosis 
and  diffuse  dermatitis.  In  wood  polishers  and  jig  sawyers  where  denatured 
alcohol  has  been  used  in  the  dressing  and  finishing  of  the  wood  or  where  acids 
have  been  used  for  checking  and  staining,  the  resultant  dust  is  more  irritating 
than  that  of  the  raw  wood  alone. 

Wounds  of  the  external  canal  from  the  entrance  of  foreign  bodies  occur, 
in  the  majority  of  instances,  upon  the  posterior-superior  wall  of  the  canal 
at  the  junction  of  the  cartilaginous  and  osseous  canal,  this  region  being  par- 
ticularly exposed  to  the  impact  of  stiff  foreign  bodies  thrust  into  the  canal 
in  the  line  of  its  long  axis  and  from  in  front,  such  injuries  having  been  recorded 
in  game  beaters  and  hunters  from  the  entrance  of  twigs  and  in  reapers  from 
grain  straws. 

The  stoppage  of  the  external  canal  by  accumulation  of  dust  is  materially 
guarded  against  by  the  growth  of  fine  hairs  projecting  across  the  lumen  of  the 
canal;  smeared  as  they  are  by  the  sticky  and  tenacious  product  of  the  cerum- 
enous  glands  they  afford  an  efficient  protection  unless,  by  forcible  washing 
and  pressure  inward,  into  the  canal,  the  accumulated  dust,  mingled  with  the 
natural  secretion  is  thrust  beyond  them  or  they  are  artificially  removed  in 
ignorance  of  their  protective  value.  The  custom  of  barbers  to  cut  hairs 
growing  from  the  inner  surface  of  the  tragus  and  about  the  entrance  of  the 
external  canal  not  only  removes  a  valuable  protection  but  allows  the  canal 
to  become  filled  with  the  cut  ends  of  the  hairs.  The  frequency  of  inflamma- 
tion of  the  external  canal  in  the  Chinese  and  some  other  oriental  peoples  is 
due  to  the  mischievous  manipulation  of  the  pubUc  barbers  who  use  a 
slender  razor  to  shave  the  hairs  in  the  external  canal,  wooden  and  metal 
scoops  or  curets  to  remove  particles  of  dry  skin,  and  pellets  of  ducks'  down  to 
wipe  out  the  canal.  All  of  these  instruments,  being  unsterilized  and  indis- 
criminately used,  not  only  mechanically  irritate  and  inflame  the  delicate 
dermis  but  infect  it,  sometimes  with  serious  results. 

Mycosis  of  the  external  canal,  usually  aspergillus  nigricans  or  flavescens, 
is  found  in  weavers,  spinners,  wool  sorters  and  other  dust  workers  handhng 
oily  substances  as  well  as  in  persons  working  in  a  moist  atmosphere,  paper 
miU  tenders  and  laundry  women  for  example,  the  condition  favorable  to  the 
development  of  the  spores  of  these  and  similar  fungi  being  an  oily  or  fatty 
soil  and  a  warm  moist  atmosphere.  The  instances  of  this  disease  as  described 
by  Wreden  in  1868  occurred  in  Russian  cavalrymen  who  anointed  their  hair 
with  grease  and  slept  in  the  moist  foul  air  of  the  barrack  stables  with  their 
horses.  The  aspergillus  is  exceedingly  tenacious  in  the  hold  of  its  mycelium 
upon  the  skin,  causes  much  irritation  and  is  disposed  of  only  by  sedulous 


342    OCCUPATIONAL  AFFECTIONS  OF  THE  NOSE,  MOUTH,  ETC. 

cleansing  and  drying  of  the  implicated  skin  area;  repeated  attacks  of  myringo- 
mycosis  aspergillina  sometimes  cause  a  thickening  of  the  dermoid  coat  of  the 
membrana  tympani  and  consequent  impairment  of  hearing. 

The  disorders  of  the  membrana  tympani  incident  to  the  trades  are  usually 
of  traumatic  origin  while  the  disturbances  of  function  of  the  remaining  por- 
tions of  the  sound  transmitting  apparatus  may  also  be  the  result  of  sources  of 
irritation  in  contiguous  and  communicating  parts,  most  commonly  the 
mucosa  of  the  nose  and  nasopharynx. 

Aside  from  direct  application  of  force  to  a  limited  area  of  its  surface,  as 
in  punctured  or  incised  wounds  of  the  membrana  tympani,  the  more  serious 
injuries  of  this  membrane  incident  to  the  trades  are  those  which  come  from 
sudden  and  considerable  variations  in  air  pressure  and  from  disruptive  force 
applied  to  the  periphery  of  the  membrane  through  the  medium  of  the  bones 
of  the  head.  Sudden  atmospheric  condensation  incident  to  unexpected 
explosions  in  mining,  blasting  and  tunnelling,  and  the  proximate  discharge 
of  artillery,  especially  in  enclosed  spaces,  may  cause  so  sudden  an  excursion 
of  the  membrana  vibrans  as  to  result  in  its  rupture.'  This  rupture  thus  pro- 
duced usually  occurs  along  the  Hne  of  the  long  process  of  the  malleus,  the 
line  of  greatest  excursion  and  most  immediate  check;  ruptures  of  this  sort 
are  usually  irregular  in  outline,  the  torn  edges  bleed  freely  and  secure,  by 
coagulation  of  the  blood,  an  apposition  of  the  edges  with  resultant  speedy 
healing  which  is  less  likely  to  be  the  case  when  the  wound  is  the  product  of 
direct  contact  and  possible  infection.  The  greater  frequency  of  concussive 
ruptures  of  the  drum-head  in  the  navy,  as  compared  with  land  artillery 
service,  is  due  to  the  condensation  of  the  concussive  effect  in  the  circumscribed 
spaces  on  shipboard,  in  the  turrets  and  shields;  the  same  is  true  of  the  concus- 
sions occurring  in  mining  operations  as  compared  with  explosive  occurrences 
in  open  trenches  or  on  a  level  in  the  open  air. 

A  similar  rupture  of  the  membrana  tympani  may  be  induced  by  a  blow 
upon  the  head,  especially  if  this  occurs  on  the  parieto-occipital  angle  of  the 
opposite  side  the  effect,  by  contrecoup,  being  to  disrupt  the  inelastic  structure 
at  the  side  of  the  circle  opposite  to  that  at  which  the  force  is  applied;  except 
in  so  far  as  the  middle  ear  is  implicated,  or  an  inflammatory  process  follows, 
the  simple  rupture  of  the  drum-head  is  liable  to  spontaneous  recovery,  but 
if  the  apposition  of  the  edges  is  incomplete,  healing  may  be  enhanced  by  the 
application  of  a  thin  paper  dressing,  appHed  on  a  moist  cotton-tipped  probe 
and  allowed  to  remain  in  place,  its  removal  being  ensured  by  the  normal  pro- 
gressive growth  of  the  dermoid  coat  of  the  drum-head  and  of  the  external 
canal. 

Another  example  of  the  effect  of  variation  in  atmospheric  pressure  is  to 
be  found  in  caisson  workers,  divers  and  aviators;  in  the  former  the  continued 
exposure  to  increased  atmospheric  pressure  with  the  subsequent  return  to 
normal  pressure,  if  incautiously  and  too  rapidly  made,  results  in  circulatory 
changes  in  the  middle  ear,  impairing  the  hearing  often  quite  as  much  as  a 


OCCUPATIONAL   INJURIES   AND   DISEASES    OF    THE   EAR  343 

solution  of  continuity  of  the  drum-head  incident  to  the  still  more  rapid 
change  in  air  pressure  constituting  a  concussion. 

The  ruptures  of  the  drum-head  incident  to  diving,  in  the  open  air,  are  com- 
monly the  result  of  accident  produced  by  sudden  condensation  of  air  in  the 
external  canal  at  the  moment  of  striking  upon,  or  entering,  the  water  while 
congestion  of  the  tympani  mucosa  and  limited  areas  of  effusion  into  the  tissues 
of  the  drum-head  with  the  creation  of  serous  or  hemorrhagic  bullae  upon  its 
outer  surface  are  the  manifestations  more  frequent  in  bell  divers  and  sub- 
marine workers  in  armor. 

In  aviators  the  rapid  alterations  of  altitude,  productive  of  circulatory 
changes  in  the  middle  ear  and  labyrinth,  as  evidenced  by  the  variable  sub- 
jective noises,  the  resultant  nervous  strain  with  the  accompanying  secondary 
contraction  of  the  tensor  tympani  muscle  and  the  subjection  to  the  continu- 
ous noise  of  the  motor  are  all  conditions  which  prove  prejudicial,  if  only 
temporarily,  to  the  hearing  power,  and  when  frequently  repeated  entail 
permanent  results. 

Variations  of  atmospheric  pressure,  moreover,  in  any  of  these  occupations, 
if  the  change  is  rapid,  are  liable  to  excite  reflex  symptoms  of  nausea  and 
vomiting  through  the  medium  of  the  effect  more  immediately  produced  in 
the  irritation  of  the  end  apparatus  in  the  semicircular  canals.  Protracted 
exposure  to  loud  sounds  of  either  very  low  or  very  high  pitch  is  Uable  to 
excite  the  same  reflex  symptoms,  tones  of  low  pitch  being  more  readily  con- 
veyed through  the  medium  of  the  earth  and  of  the  body  than  the  tones  of 
high  pitch  which  reach  the  sensorium  more  readily  through  the  medium  of 
the  air  and  the  sound-transmitting  mechanism  of  the  middle  ear. 

In  all  of  the  trades  which  entail  more  or  less  continuous  exposure  to 
heated  air  laden  with  dust  and  foul  with  poisonous  gases  the  effect  upon  the 
ear  is  secondary  to  that  induced  in  the  mucous  membrane  of  the  nose  and 
nasopharynx  and  varies,  according  to  the  degree  and  character  of  the  irrita- 
tion or  infection,  from  a  non-suppurative  progressive  thickening  process  in 
the  soft  tissues  of  the  middle  ear  to  a  suppurative  process  more  or  less  de- 
structive in  its  course. 

The  number  of  the  trades  in  which  these  two  forms  of  implication  of  the 
middle  ear  are  observable  is  large  and  their  enumeration  includes  almost  all 
of  the  occupations  which  are  conducted  in  a  dusty  atmosphere  and  those 
especially  in  which  dust  and  irritating  vapors  are  among  the  by-products 
of  manufacture;  when  to  these  unfavorable  conditions  there  is  added  the 
loud  noise  of  continuously  operative  machinery  the  cycle  of  injurious  effects, 
so  far  as  the  auditory  transmitting  and  perceptive  apparatus  is  concerned, 
is  complete  and  the  welfare  work  of  the  trades  will  not  have  become  adequate 
to  its  purpose  until  it  has  eliminated  both  dust  and  noise  as  essential 
factors. 

In  addition  to  the  obtunding  effect,  in  the  external  auditory  canal,  of 
dust  accumulations,  either  spontaneously  deposited  or  impacted  by  washing, 


344    OCCUPATIONAL  AFFECTIONS  OF  THE  NOSE,  MOUTH.,  ETC. 

with  varying  irritative  results,  according  to  the  character  of  the  dust,  distinc- 
tion in  degree  may  be  made  in  considering  the  consequences,  to  the  middle 
ear,  of  continued  occupational  exposure,  of  the  mucosa  of  the  nose  and  naso- 
pharynx, to  dust  of  varying  qualities  and  to  atmospheric  conditions  varying 
in  regard  to  temperature  and  moisture  of  the  air. 

In  mining  operations,  for  ekample,  especially  in  the  lower  levels,  the  tem- 
perature is  that  of  the  tropics  and  the  miner  pursues  his  strenuous  work  under 
conditions  which  subject  the  mucous  membrane  of  the  upper  air  passages  to  a 
moist  air  laden  with  dust  particles  more  or  less  irritating  according  to  the 
character  of  the  mining  operation.  The  moisture  in  the  air  of  the  level  and 
chambers  in  coal  mines  tends  to  throw  the  dust  down  or  to  minimize  its 
irritative  effect  upon  the  mucous  membrane,  the  disturbances  of  the  upper 
air  passages  in  miners  being  less  in  proportion  than  in  the  cases  of  miners  or 
above  ground  workmen  in  dry  dust  laden  air. 

Roepke,  who  made  personal  observations,  describes  a  coal  miner  as  com- 
ing to  the  surface  at  the  end  of  a  day's  work,  with  the  nose  and  the  naso- 
pharynx coated  with  moist  coal  dust  but,  in  a  few  hours,  entirely  free  from 
obstruction  and  the  mucous  membrane  relieved  of  its  layer  of  coal  dust, 
normally  secreting  and  free  from  excoriation. 

The  percentage  of  implications  of  the  mucous  membrane  of  the  upper  air 
passages  and  the  middle  ear  in  other  forms  of  mining  in  comparatively  dry  air 
varies  with  the  character  of  the  ore,  the  drier  air  and  the  more  penetrating 
dust  particles  being  productive  of  a  more  irritating  effect  than  that  which 
accompanies  the  mining  of  both  the  soft  and  hard  coals;  rock  dust,  more 
particularly  that  containing  metallic  particles,  is  especially  irritating,  the  most 
pronounced  cases  of  disturbance  being  found  in  the  miners  excavating  the  sili- 
cates of  copper,  of  zinc,  siliceous  quartz,  slate  rock  and  the  arsenical  ores.  In 
cases  of  exposure  to  arsenical  ore  dust  the  implication  of  the  mucous  mem- 
brane, especially  that  of  the  nose  and  nasopharynx,  seems  to  bear  a  rela- 
tionship both  in  frequency  and  in  severity,  to  the  proportion  of  arsenic  in  the 
product  mined,  suppurative  nasopharyngeal  catarrh  and,  secondarily, 
suppurative  middle-ear  inflammation  being  not  unusual,  the  nasal  mucous 
membrane  covering  the  cartilaginous  septum  showing  a  predilection  as  a 
locality  for  the  resultant  circumscribed  swellings  and  ulcerations.  In  the 
more  chronic  cases  of  arsenical  poisoning  Lewin  has  reported  inflammation 
of  the  internal  ear  as  a  sequence  of  the  evidence  of  arsenical  poisoning  in  the 
nasopharynx  and  middle  ear.  In  mercury  mining  the  initial  lesions  occur 
most  commonly  in  the  mouth,  the  nasopharynx  being  comparatively  unaf- 
fected but  in  the  more  severe  cases  of  mercurial  poisoning  Wolf  has  observed 
acute  labyrinthitis  accompanied  by  Meniere's  complex  of  symptoms. 

In  all  mining  operations  there  must  always  be  taken  into  consideration, 
in  addition  to  the  air  contaminations  of  natural  origin,  those  which  are 
artificially  produced  as  a  part  of  the  process  of  mining,  adding  the  fumes 
resultant  from  the  explosion  of  gunpowder  and  dynamite  and  also  endanger- 


OCCUPATIONAL   INJURIES   AND   DISEASES   OF    THE   EAR  345 

ing  the  ear  through  the  concussive  effect  of  the  explosion  confined  within  a 
limited  space. 

In  all  of  the  chemical  industries  the  similar  contamination  of  the  air  by 
the  liberation  of  acid  fumes  becomes  a  factor  in  the  production  of  nasopharyn- 
geal irritation  and  consequent  implication  of  the  middle  ear  while  the  various 
dust-producing  trades,  exercised  above  ground  but  in  the  circumscribed 
spaces  of  factories,  mill  rooms,  and  workshops,  vary  in  the  degree  of  irrita- 
tion produced  according  to  the  constitution  of  the  dust  and  its  ponderability. 
The  coarser  dusts  resulting  from  jig  sawing  and  other  forms  of  wood  working 
would  be  less  deleterious  but  for  the  acids  and  oils  and  varnishes  with  which 
the  wood  has  been  permeated  or  covered  in  previous  steps  of  the  process 
toward  the  finished  product,  while  the  weight  of  the  finer  dust  resulting  from 
metal,  stone,  and  glass  cutting,  grinding,  and  polishing,  incisive  and  irritat- 
ing in  itself,  makes  it  less  prejudicial  to  the  artizan  because  of  lesser  pro- 
longation of  suspension  in  the  air. 

The  exceptions  to  this  rule  are  the  trades  in  which  the  worker  is  in  close 
relationship  to  a  machine  producing  a  dust  of  a  mechanically  irritating  qual- 
ity and  of  little  ponderability,  such  as  metal  burnishing,  glass  grinding  and 
mother-of-pearl  cutting,  lime  burning,  fertilizer  mixing  and  packing  and  also 
the  trades  dealing  with  wool,  hair,  and  grass  sorting,  packing  and  upholster- 
ing, flax  heckeling,  jute  and  hemp  spinning,  in  which  the  infectious  nature  of 
the  dust  favors  the  inception  of  suppurative  disease. 

Under  modern  processes  of  manufacture  the  majority  of  the  trades  are 
conducted  through  the  intervention  of  machinery  interposed  between  the 
workman  and  the  material  employed  with  the  resultant  introduction  of 
another  prejudicial  factor,  especially  and  continuously  invading  the  organ  of 
hearing  and  even,  in  some  instances,  affecting  that  other  portion  of  the  inter- 
nal ear  which  is  a  peripheral  organ  of  equilibration,  it  being  clinically  observ- 
able that  high  grades  of  impairment  of  hearing  are  more  common  among  those 
metal  workers  whose  day  labor  confines  them  to  subjection  to  intense  sounds 
made  up  largely  of  overtones  of  high  pitch  than  among  the  workers  in  noises 
of  lower  pitch,  beamers  in  cotton  mills  for  example. 

Gottstein  and  Kayser  found  marked  impairment  of  hearing  in  50  per 
cent,  of  smiths  and  machinists  examined  by  them.  Holt  found  marked 
impairment  of  hearing  in  35  per  cent,  of  coppersmiths,  and  Barr  found  normal 
hearing  in  a  little  over  9  per  cent,  only  of  boiler  makers,  while  Habermann 
reports  that  out  of  31  boiler  makers  there  was  not  one  with  normal  hearing. 

The  consensus  of  opinion  is  to  the  effect  that  the  degree  of  impairment  of 
hearing  in  all  these  cases  had  a  definite  relationship  to  the  duration  and  the 
intensive  character  of  the  operative  sound.  Both  ears  were  usually  tested, 
but  more  particularly  that  which  was  habitually  directed  toward  the  sound 
source.  Subjective  noises  were  an  almost  unvarying  accompaniment  of  the 
impairment  of  hearing  but  dizziness  or  vertigo  was  present  only  in  the  more 
advanced  cases,  where  the  upper  tone  limit  in  hearing  was  notably  decreased. 


346         OCCUPATIONAL   AFFECTIONS    OF    THE    NOSE,    MOUTH,    ETC. 

Dizziness  is  also  more  likely  to  be  an  accompanying  symptom,  in  mill  and 
factory  operatives,  when  to  the  noise  of  the  machinery  there  is  added  a 
sensible  vibration. 

The  majority  of  authorities  deahng  with  this  subject  regard  the  affection 
of  the  hearing  incident  to  exposure  to  loud  sounds  of  high  pitch  as  one  of 
the  internal  ear  solely,  but  Holt  expresses  the  opinion  that  changes  in  the 
middle  ear  and  sound  transmitting  apparatus  are  mainly  the  cause  of  the 
inpairment  of  hearing  and  Gradenigo  makes  three  differentiations:  laby- 
rinthitis without  middle-ear  implication,  chronic  catarrhal  middle-ear  disease 
with  labyrinthitis,  and  chronic  advanced  middle-ear  inflammation  with 
imphcation  of  the  labyrinth  and  vertigo  as  an  accompanying  symptom; 
while  Ropke  is  of  the  opinion  that  the  majority  of  the  cases  of  impaired 
hearing  consequent  upon  exposure  to  loud  noise  are  a  combination  of  a  dis- 
turbance of  the  labyrinth  and  of  a  catarrhal  process  in  the  middle  ear,  and 
Urbantschitsch  reports  a  case  in  which  the  concussion  of  the  labyrinth  was 
accompanied  by  contraction  of  the  intrinsic  muscles  of  the  middle  ear. 

These  occupational  sounds  are  divisible  into  two  classes:  sounds  of 
sudden  access  and  considerable  amplitude,  detonations,  for  example;  and 
sounds  of  prolonged  duration,  intensive,  of  high  pitch  and  replete  with  metal- 
lic overtones. 

In  all  the  clinical  observations  in  regard  to  the  effect  of  sound  waves  of 
considerable  amplitude  aerially  conveyed,  as  a  part  of  the  occupational 
inroad  upon  the  organ  of  hearing,  the  evidence  is  mainly  in  favor  of  the  sup- 
position that  the  principal  channel  through  which  the  internal  ear  is  subjected 
to  injury  from  this  source  is  that  through  the  medium  of  the  sound-transmit- 
ting apparatus  of  the  middle  ear  and  not  through  other  bodily  channels; 
this  view  being  further  supported  by  the  fact  that  it  is  not  the  tones  of  me- 
dium low  pitch,  those  most  readily  transmitted  by  bone  conduction,  which  are 
the  operative  factors  in  the  causation  of  the  progressive  impairment  of  hearing 
in  the  majority  of  the  cases  of  occupational  origin,  but  those  of  comparatively 
high  pitch  which  find  their  access  to  the  internal  ear  through  the  sound- 
transmitting  apparatus  only  because  of  the  obstacle  presented  to  the  pas- 
sage of  their  short  sound  waves  through  the  soft  tissues  of  the  body  in  which 
their  impulse  is  almost  immediately  lost. 

The  mass  of  reported  cUnical  observations  upon  this  subject  has  found 
its  more  intimate  support  in  physiological  experimentation  only  within  a 
few  years  and  that  by  a  series  of  investigations  made  by  individual  observers, 
but  often  in  collaborative  relationship,  their  purpose  being  the  exact  deter- 
mination of  the  effects  produced  in  the  acoustic  labyrinth  as  the  result  of 
subjection  of  animals  to  the  continued  influx  of  loud  noises  of  different  kinds. 

The  majority  of  these  experiments  included  the  use  of  very  high  pitched 
tones  produced  by  whistles,  organ  pipes,  high-pitched  metallic  bodies  of 
various  kinds,  and  metalHc  sounds  of  lower  pitch  under  resonance  conditions 
simulating  those  of  the  trades  as  exhibited  in  factory  operatives,  machinists, 


OCCUPATIONAL   INJURIES   AND   DISEASES    OF    THE   EAR  347 

and  boiler  makers,  the  general  results  of  these  observations  being  that  the 
exposure  of  one  or  both  ears  continuously,  for  a  period  of  several  days  or 
weeks,  to  a  pure  tone  of  high  pitch  or  to  a  mixed  tone  of  medium  low  pitch, 
with  correlated  high-pitched  overtones,  was  followed  by  a  degenerative  proc- 
ess in  the  organ  of  Corti,  beginning  in  the  nucleated  ciliated  cells,  progress- 
ing to  the  neuron,  and  then,  secondarily,  attacking  the  vibrating  mechanism 
and  extending  to  the  contiguous  membranous  labyrinth. 

The  degenerative  process  was  found  to  bear  a  measure  of  relationship  to 
the  intensity  and  duration  of  appUcation  of  the  invasive  tone  and  to  be 
situated  in  corresponding  relationship  in  the  upper  part  of  the  first  and  the 
beginning  of  the  second  whorl  of  the  cochlea. 

Where  one  ear  was  closed  to  the  extent  of  preventing  the  entrance  of 
sound  waves  through  the  normal  external  passage,  the  cochlea  exposed  to 
the  sound  waves  was  alone  found  to  have  undergone  a  degenerative  process. 
Von  Eichen,  for  example,  stopped  the  left  ear  air-tight  in  one  experiment  and, 
subjecting  the  animal  to  a  whistle  tone  of  C5,  found  only  the  right  laby- 
rinth affected  by  the  characteristic  degenerative  process,  the  left  labyrinth 
remaining  normal.  Care  was  taken,  in  the  majority  of  the  experiments,  to 
transmit  these  experiment  tones  aerially  only  and  not  through  the  medium 
of  the  cage  or  box  in  which  the  animal  was  confined  and  consequently  through 
the  body. 

Gruenberg  exposed  the  right  ear  of  a  pigeon  from  7  to  14  days  to  the 
continuous  tones  of  a  Bezold-Edelmann  whistle  A3,  A4  with  resultant  evi- 
dences of  degenerative  processes  in  the  papilla  acoustica  up  to  one-quarter 
the  length  of  the  ductus  cochlearis,  the  left  ear  remaining  normal. 

Hoessli  used,  as  the  container  for  his  animals,  a  suspended  section  of  an 
iron  water  pipe,  struck  by  automatic  hammers  to  reproduce  the  conditions 
to  which  boiler  makers  are  subjected,  one  ear  being  closed  by  cotton  and 
collodion  and,  in  some  instances,  both  ears,  in  order  to  determine  the  effect 
of  the  sound  corporeally  conveyed.  Where  one  ear  was  closed  the  degen- 
erative process  was  exhibited  in  the  ear  remaining  open;  where  both  ears  were 
closed  the  degenerative  process  was  not  exhibited,  the  observer  concluding 
that  air  conduction  was  the  only  medium  through  which  the  acoustic  effect 
was  produced  and  that  the  ossicular  chain  is  a  conductive  and  not  a  pro- 
tective mechanism. 

In  concurrence  with  the  determinations  of  other  observers  Hoessli  found 
that  the  labyrinth  lesion  occurred  in  relatively  the  same  area  in  the  cochlea 
in  all  the  animals  subjected  to  the  influence  of  a  continuous  tone  of  high 
pitch,  and  that  the  higher  the  tone  the  lower  was  the  area  of  lesion  in  the 
cochlear  tube,  while  Habermann,  in  the  observations  made  upon  boiler  makers 
and  blacksmiths,  found  that  the  degenerative  alterations  in  the  organ  of 
Corti,  in  the  nerve,  and  in  the  related  ganglion  cells  was  more  extensive  in  the 
basal  whorl,  the  upper  portion  of  the  cochlea  remaining  normal. 

Wittmarck  found  that  with  intense  sounds  of  high  pitch  and  even  of  short 


348         OCCUPATIONAL   AFFECTIONS    OF    THE    NOSE,    MOUTH,    ETC. 

duration  the  corresponding  area  in  the  cochlea  was  affected,  in  contradis- 
tinction to  other  observers,  but  placed  especial  stress  upon  the  influence 
exerted  by  influx  of  sound  corporeally  conveyed. 

Marx  is  of  the  opinion,  from  a  corresponding  series  of  investigations,  that 
the  local  degenerative  process  in  the  organ  of  Corti  is,  in  proportion  to  the 
intensity  of  the  high  pitch  employed,  not  only  more  pronounced  but  also 
more  extensive  in  area;  the  high  tones  of  a  continuously  blown  whistle,  A3 
and  A4,  produced  the  recognized  degenerative  effects  in  the  organ  of  Corti; 
corresponding  tones  of  lower  pitch  A 2  and  E2,  being  less  intense,  did  not 
result  in  degeneration. 

In  the  detonation  experiments  of  HoessU  only  the  upper  portion  of  the 
first  whorl  and  the  lower  portion  of  the  second  whorl  were  affected,  a  result 
consonant  with  the  results  of  Siebenmann  and  others  and  with  the  clinical 
observations  of  Friedrich  and  Jaehne,  while  Yoshii  reports,  as  the  result 
of  detonation  with  middle-ear  injury,  rupture  of  the  membrane  of  the  round 
window  in  but  one  case,  the  membranes  of  the  oval  and  round  windows  re- 
maining intact  notwithstanding  the  presence  of  petechias  and  hemorrhage 
in  the  vicinity  of  the  windows,  there  being  corresponding  changes  in  all 
parts  of  the  organ  of  Corti,  the  outer  and  inner  cihated  cells  being  swollen, 
distorted  and  sometimes  separated  from  their  base,  the  rods  distorted  and  the 
intermediate  space  filled  with  cellular  detritus. 

Clinical  experience  has  shown  that  with  continued  exposure  of  the  human 
subject  to  intense  sounds  of  high  pitch  there  is  evoked,  in  addition  to  a  sense 
of  fullness,  subjective  noise  and  malaise,  a  greater  or  less  degree  of  dizziness; 
and  the  laboratory  evidences  of  the  location  of  degenerative  changes  in  the 
lower  portion  of  the  cochlea  suggest  the  possibility,  in  view  of  the  vestibular 
contiguity,  of  a  possible  secondary  excitation  of  the  equilibrating  end  organ. 

While  the  demonstration  of  labyrinthine  changes  has  been  sufficiently 
precise  and  sufficiently  extensive  to  emphasize  the  importance  of  prophylac- 
tic measures  in  reference  to  the  noises  of  the  trades,  there  is  another  question 
still  a  matter  of  debate  and  open  to  clinical  observation  for  its  determination, 
and  that  is  the  possible  secondary  implication  of  the  sound-transmitting 
apparatus  of  the  middle  ear,  a  change  progressively  decreasing  the  con- 
ductivity in  the  channel  through  which  the  causative  factor  in  the  cochlear 
degeneration  finds  access  to  the  internal  ear. 

Hensen,  Bockendahl,  and  Pollak  have  reported  observations  of  apparent 
reflex  contraction  of  the  tensor  tympani  muscle  in  response  to  high  tones, 
and  it  is  a  not  uncommon  clinical  experience  to  find  in  boiler  makers,  machin- 
ists, locomotive  engineers  and  firemen,  in  addition  to  a  decrease  in  hearing  for 
tones  of  medium  and  high  pitch,  both  by  bone  conduction  and  aerially  con- 
veyed, objective  changes  in  the  sound-transmitting  apparatus  of  the  middle 
ear  evidencing  a  thickening  of  the  tympanic  mucosa  and  a  contraction  of  the 
tensor  tympani  muscle,  conditions  referable  in  many  instances  to  such  other 
occupational  influences  as  sudden  changes  in  temperature  and  exposure  to 


OCCUPATIONAL    INJURIES    AND    DISEASES    OF    THE    EAR  349 

dust,  and  other  causes  inducing  irritation  of  the  nasal  and  nasopharyngeal 
mucous  membrane. 

In  the  earlier  stages  of  impairment  of  hearing  as  the  result  of  exposure  to 
loud,  continuous  noise,  clinical  observation  shows  a  depression  of  the  mem- 
brana  tympani  consequent  upon  retraction  of  the  tensor  tympani  muscle, 
this  objective  evidence  appearing  in  advance  of  the  thickening  process  in  the 
middle  ear. 

Further  observations  in  the  cases  of  workers  in  loud  noises  serve  to  sub- 
stantiate the  idea  that  the  muscular  contracture  and  consequent  fixation 
of  the  sound-transmitting  apparatus,  supplemented  by  the  thickening  of  the 
tympanic  mucosa,  serve  as  an  obstacle  to  the  inroad  of  those  loud  and  high- 
pitched  sounds  which  have  been  shown,  by  animal  experimentation,  to  find 
their  access  to  the  labyrinth,  with  deleterious  effect,  especially  through  the 
natural  channel  of  audition. 

Similar  changes,  more  especially  the  muscular  contracture,  have  been 
found  in  telephone  operators,  and  are  more  probably  the  result  of  the  sudden 
and  unexpected  movements  of  the  telephone  armature  in  response  to  current 
interruptions  than  of  the  normal,  ordinary  use  of  the  instrument  in  listening  to 
the  human  voice,  measurements  of  the  intensity  of  the  voice  at  the  receiving 
instrument,  as  compared  with  that  at  the  transmitting  end  of  the  line,  having 
shown  so  considerable  a  loss  as  to  make  the  volume  of  voice  received  a  very 
inconsiderable  percentage  of  that  immediately  transmitted,  while  the  con- 
centration of  the  voice  directly  upon  the  ear  of  the  operator,  as  is  the  case  in 
the  majority  of  the  forms  of  apparatus  including  close  adjustment  of  the 
telephone  receiver,  makes  the  determination  of  even  a  very  moderate  tone  a 
matter  of  custom  without  effort  except  in  so  far  as  accommodation  to  the 
qualitative  overtones  of  the  consonant  sounds  of  nearest  resemblance  is 
concerned. 

Repeated  observations,  made  at  intervals,  in  the  cases  of  telephone 
operators  with  normal  or  approximately  normal  hearing  have  shown  that  very 
little  change  in  the  hearing,  even  in  years  of  service,  results  from  the  occupa- 
tion, but  that  with  changes  in  the  sound-transmitting  apparatus  with  appre- 
ciable diminution  of  hearing  upon  entering  the  service,  a  further  diminution 
is  noticeable  after  prolonged  occupation  in  telephone  work. 

The  demand  upon  the  normal  hearing  power  in  telephone  operation  would 
seem,  therefore,  to  be  so  little  in  excess  of  the  usual  conversational  demand 
as  to  cause  no  resultant  defect. 

The  sum  of  the  recorded  statistics  of  observations  in  this  rapidly  increas- 
ing branch  of  public  utility  service  is  too  small  to  make  other  than  very  broad 
and  very  general  conclusions  possible,  and  the  subject  is  one  which  might 
advisedly  receive  more  attention  on  the  part  of  the  medical  profession. 

Among  the  most  complete  are  the  conclusions  arrived  at  by  Blegvad  as 
the  result  of  a  series  of  precisely  conducted  observations,  embodied  in  an 
extended  record    beyond  the  capacity  of  a  brief  review  but  well  repaying 


350    OCCUPATIONAL  AFFECTIONS  OF  THE  NOSE,  MOUTH,  ETC. 

careful  reading,  to  the  following  effect:  In  26.4  per  cent,  of  the  371  telephone 
operators  with  normal  hearing,  who  were  made  the  subject  of  examination, 
there  was  a  retraction  of  the  drum-head  in  the  ear  to  which  the  receiving 
instrument  was  usually  applied,  the  other  ear  evidencing  either  none  or 
only  a  slight  retraction.  The  continued  use  of  the  telephone  caused  no  depre- 
ciation of  the  hearing  in  operators  with  normal  ears,  nor  was  there,  on  the 
other  hand,  any  appreciable  increase  in  the  capacity  for  the  hearing  of  tones  of 
high  pitch  and  slight  intensity,  as  is  sometimes  claimed  by  the  operators,  this 
claim  being  supported  rather  by  the  increase  in  the  accommodative  power  for 
tones  of  this  class  and  by  the  gradually  acquired  habit  of  eliminating  mentally 
the  coincident  and  the  extraneous  noises.  The  aural  lesions  and  traumatic 
neurosis  incident  to  the  accidental  introduction  upon  the  line  of  strong 
currents  are  the  result  of  the  exhibition  of  a  loud  and  sudden  sound  and 
are  to  be  guarded  against  by  proper  protective  construction  in  the  telephone 
lines. 

It  is  evident,  therefore,  that  in  addition  to  the  occupational  conditions 
which  should  come  under  the  consideration  of  welfare  work  as  they  have  been 
previously  regarded,  there  should  be  especial  attention  given  systematically, 
both  by  study  of  cause  and  efifect  and  by  effort  at  protection  from  the  results 
of  continued  exposure  to  loud  and  especially  penetrating  noises. 

The  sound-transmitting  apparatus  of  the  middle  ear  serves  the  double  pur- 
pose of  sound  transmission  and  of  protection  to  the  transmitting  and  percep- 
tive mechanism  beyond  it,  but  is  capable  of  exerting  this  office  only  for  periods 
of  Hmited  duration  and,  under  conditions  of  continuous  subjection  to  loud 
sounds,  covering  a  limited  portion  of  the  audible  scale,  in  itself  becomes  fati- 
gued and  incapable  of  exercising  its  protective  office.  The  obstacle  presented 
to  the  passage  of  sounds  of  short  wave  lengths  through  the  soft  tissues  of  the 
body  affords  a  certain  measure  of  protection  in  one  direction,  and  the  obtund- 
ing  of  the  external  auditory  canal  prevents  the  influx  of  the  objectionable 
sound  through  that  natural  passage,  but  this  serves  as  only  a  partial  protec- 
tion and  an  important  step  in  the  welfare  work  of  the  trades  will  be  in  the 
elimination  of  that  offensive  and  injurious  by-product  of  mechanical  action, 
sustained  and  unnecessary  noise. 


DIVISION  V 

Occupational  Affections  of  the  Skin. 

Cancer  and  Occupation.  X-ray.  Radium 

CHAPTER  I 
OCCUPATIONAL  AFFECTIONS  OF  THE  SKIN 

BY  JOHN  T.  BOWEN.  M.  D.,  Boston,  Mass. 

Dermatitis  Venenata. — The  term  dermatitis  venenata  has  been  given  to 
that  class  of  inflammations  of  the  skin  that  is  produced  by  external  contact 
with  irritating  agencies,  whether  of  a  soHd,  liquid  or  gaseous  nature.  These 
agencies  may  be  of  very  different  character,  and  may  belong  to  the  animal, 
vegetable  or  mineral  world.  No  pathognomonic  symptoms  or  appearances 
are  associated  with  this  class  of  inflammations,  although  certain  more  or  less 
general  characteristics  may,  if  present,  serve  to  distinguish  them.  James  C. 
White,  in  his  classical  monograph  on  Dermatitis  Venenata,  enumerates  among 
these  characteristics  "mainly  a  sudden  onset,  a  rapid  evolution  of  primary 
lesions,  some  peculiarities  in  their  situation  within  the  cutaneous  tissues,  an 
unusual  color  in  their  fluid  contents,  a  greater  intensity  of  inflammatory  ac- 
tion, and  continuity  of  development  within  given  areas,  the  localities  attacked 
and  the  sharply  defined  limitations  of  the  regions  affected,  a  marked  asym- 
metry and  an  artificial-appearing  configuration  in  the  eruption,  their  occur- 
rence in  those  employed  in  certain  arts  and  professions,  and  other  unusual  ex- 
traordinary appearances  at  times,  which  cannot  be  defined."  On  the  whole 
the  greatest  number  of  cases  of  dermatitis  venenata  is  produced  by  the  action 
of  plants  possessing  irritating  properties,  and  foremost  among  these  poison- 
ous species  may  be  mentioned  the  different  varieties  of  rhus:  poison  ivy, 
poison  sumach,  etc.  Other  frequent  causes  of  dermatitis  venenata  are  the 
use  of  irritating  cosmetics,  and  clothing  which  has  been  colored  by  poisonous 
dyes.  The  French  writers  often  group  these  cases  of  dermatitis  venenata 
under  the  broad  conception  of ''eruptions  artificielles, "  which  includes  feigned 
eruptions,  eruptions  of  digestive  origin,  eruptions  from  external  and  internal 
medicaments,  therapeutic  eruptions,  and  professional  eruptions. 

Much  emphasis  should  be  laid  on  dermatitis  venenata  in  a  chapter  dealing 
with  the  professional  dermatoses,  because  by  far  the  larger  number  of  cases  of 
these  affections  belongs  to  the  former  group.  The  so-called  trade  eczemas, 
affecting  chiefly  the  hands  and  the  parts  exposed  to  contact  with  the  irri- 
tating substances  handled  in  various  trades,  are  forms  of  dermatitis  venenata, 
at  least  at  the  outset  and  etiologically,  before,  in  other  words,  the  element  of 

351 


352  OCCUPATIONAL  AFFECTIONS  OF  THE  SKIN 

chronicity  and  stubbornness  that  is  associated  with  the  term  eczema  has 
asserted  itself.  These  so-called  trade  eczemas  are  the  most  common  ex- 
amples of  occupational  dermatoses  and  will  be  considered  in  this  chapter 
under  the  eruptions  peculiar  to  the  various  occupations. 

Trade  Stigmata. — Before  describing  the  various  occupational  dermatoses 
that  may  properly  be  included  under  this  title,  a  word  may  be  said  with  regard 
to  the  so-called  trade  stigmata.  This  name  has  been  given  to  those  changes 
in  the  skin,  caused  by  various  occupations,  which  are  not  of  sufficient  patho- 
logical importance  to  be  classed  as  dermatoses,  and  which  may  yet  be  quite 
typical  and  characteristic  of  the  work  in  which  the  subject  is  engaged. 
They  often  consist  in  a  simple  coloring  or  circumscribed  thickening  of  the  skin 
due  either  to  exposure  to  the  sun  or  to  the  mechanical  effects  of  constant 
pressure.  Such  appearances  of  the  skin,  while  of  no  great  consequence  as 
regards  their  symptoms  to  the  one  by  whom  they  are  acquired,  may  be  im- 
portant from  a  medico-legal  point  of  view.  In  the  case  of  dyers  and  of  those 
who  work  in  aniline  manufacturies,  an  obstinate  staining  may  resist  all  efforts 
to  clean  the  hands  at  the  end  of  the  working  day.  The  strong  alkalies  and 
other  substances  that  are  often  employed  to  aid  in  cleansing  may  be  very 
injurious  to  the  skin  as  will  be  later  emphasized,  and  give  rise  to  an  active 
inflammation.  Exposure  to  the  sun's  rays  in  the  case  of  cabmen,  sailors,  sol- 
diers, etc.,  causes  the  reddening  and  later  bronzing  that  are  associated  with  an 
out-of-door  life,  and  that  may  often  reveal  the  occupation  of  the  subject 
by  their  intensity  and  localization.  In  this  case  the  reddening  and  pig- 
mentation are  to  be  regarded  as  protective  phenomena  against  greatly  in- 
creased action  of  the  sun's  rays. 

Thickening  of  the  skin  may  occur  either  diffusely  or  in  circumscribed 
patches,  when  constant  pressure  or  friction  is  brought  to  bear  on  certain  places 
in  the  performance  of  different  kinds  of  work.  The  inner  surface  of  the  hands 
of  those  who  engage  in  almost  any  kind  of  rough  manual  labor  tends  to  become 
thickened,  this  being  due  chiefly  to  the  piling  up  of  the  horny  cells  of  the  outer 
epidermic  layer.  From  circumscribed  thickenings,  callous  places,  a  hint  may 
be  given  as  to  the  occupation  of  the  subject,  and  in  this  way  the  skin  changes 
may  be  of  value  in  medico-legal  matters.  Thus  shoemakers  exhibit  callous 
patches  on  the  flexor  surface  of  the  right  hand  from  the  pressure  from  the 
hammer,  also  circumscribed  thickening  in  the  sacral  and  coccygeal  regions 
on  account  of  their  constant  sitting.  Tailors,  blacksmiths  and  carpenters 
are  affected  with  similar  cutaneous  thickenings  at  the  site  of  pressure  from  the 
tools  that  they  use,  on  various  parts  of  their  fingers.  Analogous  appearances 
are  observed  sometimes  in  musicians,  those  who  play  on  stringed  instruments 
showing  callous  thickenings  at  the  end  of  the  thumb  and  forefinger.  A  cir- 
cumscribed thickening  of  the  skin  of  the  neck  is  occasionally  observed  in 
violin  players  from  the  constant  irritation  caused  by  the  violin  pressing  upon 
this  spot. 

With  regard  to  the  discolorations  of  the  skin,  apart  from  the  bronzing 


OCCUPATIONAL  AFFECTIONS  OF  THE  SKIN  353 

and  pigmentations  that  occur  in  those  whose  occupation  exposes  them  to 
the  weather  and  to  the  sun's  rays,  there  are  several  conditions  produced  by 
the  penetration  of  foreign  bodies  into  the  skin.  Blaschko  has  described  an 
affection  common  in  workers  in  silver,  in  which  small  spots  from  the  size  of 
a  pin's  head  to  that  of  a  pea,  of  a  bluish-black  color,  appear  on  the  hands  and 
fingers,  especially  on  the  dorsal  surface  of  the  left  hand.  These  spots  do  not 
tend  to  disappear  with  time  but  are  permanent,  remaining  of  just  the  same 
appearance  after  they  have  attained  a  certain  size.  The  bluish-black  color 
is  produced  by  the  penetration  of  very  small  particles  of  silver  through  the 
epidermis  into  the  corium,  in  the  process  of  filing,  sawing  and  planing.  The 
silver  is  then  dissolved  in  the  alkaline  tissue  fluids  and  again  precipitated  in 
the  form  of  very  fine  particles,  which  are  deposited  in  the  connective  tissue 
and  elastic  fibers.  Lewin  regards  the  lymph  channels  as  the  place  of  de- 
position of  the  silver. 

Similarly  Elliot,  in  1891,  described  a  "pseudo-pigmentation  on  the  hands 
of  millers."'  His  case  concerned  a  man  whose  occupation  was  to  smooth 
off  with  a  steel  chisel  the  roughnesses  that  occurred  every  day  in  the  grinding 
stone,  and  on  the  backs  of  whose  hands  and  fingers  there  were  numerous 
dark  discolored  spots  varying  in  tint  from  brown  to  black,  some  of  them  as 
large  as  a  pea.  These  were  caused  by  the  small  particles  of  metal  that  were 
chipped  oft"  constantly  in  the  course  of  this  work.  The  discolored  spots 
were  evidently  caused  by  the  oxidation  of  the  small  bits  of  metal,  and  it  was 
shown  that  when  the  cause  was  removed,  there  was  gradual  elimination  of 
the  rust  particles.  These  discolorations  in  millers  have  been  confirmed  by 
others,  and  the  dorsal  aspect  of  the  left  hand  has  been  shown  to  be  their 
most  common  seat.  They  have  been  used  by  Tardieu  as  a  means  of  identi- 
fication. 

Occupational  Dermatoses  Proper. — In  almost  all  the  cases  in  which 
poisonous  material  is  introduced  into  the  economy  through  the  skin,  there  is 
a  fracture  or  opening  of  the  integument,  however  small,  at  the  point  of 
contact.  Tuberculosis,  syphiHs,  glanders  and  other  serious  systemic  in- 
fections are  thus  introduced,  and  there  is  no  good  reason  for  assuming  that 
these  noxious  bacterial  agents  can  pass  through  a  wholly  intact  epidermis. 
An  exception  to  this  rule  is  found  notably  in  the  case  of  mercury,  which,  as 
is  well  known,  may  produce  severe  constitutional  and  poisonous  effects 
after  its  absorption  through  the  unbroken  skin,  and  also  in  such  cases  may 
produce  a  universal  and  even  dangerous  form  of  dermatitis.  Somewhat 
analogous  to  this  dermatitis  from  mercurial  intoxication  is  a  form  described 
as  occurring  in  workers  in  aniUne  factories  and  in  dye  houses,  which  runs  an 
exceedingly  acute  and  virulent  course.  It  starts  as  an  acute  dermatitis, 
beginning  on  the  exposed  portions — hands  and  face — and  showing  its  most 
active  characteristics  in  those  places.  From  here  it  spreads  to  the  arms, 
trunk  and  lower  extremities.  The  affection  may  be  confined  to  the  erythe- 
matous stage,  causing  much  oedema  of  the  hands,  ears,  penis  and  scrotum,  or 
23 


354  OCCUPATIONAL  AFFECTIONS  OF  THE  SKIN 

it  may  progress  to  a  quite  intense  bullous  dermatitis,  with  large  and  small, 
often  confluent,  bullae,  followed  by  a  long-lasting  and  profuse  desquamation. 
When  the  feet  are  more  acutely  affected  than  the  hands,  it  can  usually  be 
shown  that  the  subjects  have  been  working  without  stockings  or  other 
protective  covering.  This  affection  has  a  definite  course  and  is  followed  by 
a  marked  idiosyncrasy  to  this  form  of  poisoning.  It  is  assumed  that  in  this 
case  certain  toxic  substances  find  their  way  through  the  intact  epidermis  to  the 
deeper  parts  of  the  skin,  expending  their  action  especially  on  the  vessels  of 
the  skin.  Blaschko  gives  a  Hst  of  19  colors  with  which  such  a  type  of  der- 
matitis has  been  observed,  but  points  out  that  they  must  not  be  looked 
upon  as  generally  poisonous  substances,  inasmuch  as  a  certain  idiosyncrasy 
seems  to  be  necessary  in  the  persons  affected.  Such  forms  of  dermatitis 
have  also  been  observed  in  the  case  of  workers  in  quinine  factories,  in  those 
who  have  to  handle  various  foreign  woods,  satinwood,  teak,  etc. 

Dermatitis,  Usually  of  an  Eczematous  Type. — By  far  the  larger  number 
of  cases  of  occupational  dermatoses  are  exhibited  in  the  form  of  a  derma- 
titis of  an  eczematous  type,  and  most  of  them  come  under  the  commonly 
used  heading  "trade  eczema."  It  does  not  come  within  the  scope  of  this 
article  to  discuss  at  any  length  the  much  mooted  question  of  eczema,  in- 
cluding the  application  and  limitation  of  this  term.  Many  of  the  cutaneous 
disturbances  caused  by  the  occupations  produce  an  acute  dermatitis  very 
similar  to,  if  not  indistinguishable  from,  an  ordinary  dermatitis  venenata, 
caused  in  the  same  way  by  the  direct  contact  with  poisonous  or  irritating 
substances.  Most  of  these  inflammations  affect  the  hands,  head,  or  what- 
ever parts  of  the  body  may  be  exposed  to  direct  contact  with  the  irritat- 
ing substance.  Those  who  hold  to  the  older  view  class  these  as  cases  of 
acute  eczema,  their  recurrence  and  persistence,  whether  by  continued  ex- 
posure to  the  primary  exciting  cause,  or  without'  this  objective  incentive, 
placing  them  in  the  group  of  chronic  eczemas.  A  very  large  number  of  the 
cases  of  occupational  dermatitis  begin,  as  will  be  seen  in  the  course  of  this 
article,  in  quite  a  different  way,  going  through  no  preliminary  acute  stage, 
but  presenting  the  various  clinical  features  common  to  ordinary  cases  of 
eczema  to  which  no  definite  external  causation  can  be  assigned. 

These  cases  of  occupational  dermatitis,  or  "  trade  eczemas,"  form  an  aston- 
ishingly large  proportion  of  the  total  number  of  cases  seen  in  the  dermatolog- 
ical  departments  of  hospitals.  Fordyce  has  stated  that  at  his  clinic  at  the 
University  and  Bellevue  Hospital  Medical  College  about  2  per  cent,  of  the 
total  number  of  new  cases  for  191 1  constituted  occupational  dermatoses. 
The  great  majority  of  these  were  of  the  type  known  as  trade  eczemas,  and 
while  a  good  many  of  them  yielded  readily  to  treatment,  a  considerable  num- 
ber proved  refractory,  and  necessitated  abandonment  of  the  particular  work 
for  a  time,  or  changing  of  occupation.  Knowles  reviewed  24,459  cases  of 
diseases  of  the  skin  that  had  been  seen  by  him  during  9  years  at  the  derma- 
tological  departments  of  the  Pennsylvania  University  and  Howard  Hospitals. 


OCCUPATIONAL  AFFECTIONS  OF  THE  SKIN  355 

Of  this  number  4142  were  diagnosticated  as  eczema,  and  of  these  768  were 
from  distinctly  occupational  causes.  He  points  out  that  this  estimate  in- 
cluded only  those  cases  where  there  was  direct  exposure  from  the  occupation, 
and  cases  of  eczema  rubrum,  for  example,  that  were  evidently  produced  by 
long  standing  at  various  occupations,  were  not  considered. 

It  is  a  matter  of  common  knowledge  that  not  all  persons  who  are  exposed 
to  cutaneous  irritants  are  affected  adversely  by  them.  This  is  well  seen  in  the 
exemption  of  many  people  from  poisoning  by  ivy  and  other  plants  which 
may  produce  a  severe  dermatitis  in  others.  In  the  same  way  not  all  the 
workmen  exposed  to  the  same  conditions  in  their  particular  trade  are  similarly 
affected  by  them.  Others,  after  once  exhibiting  a  susceptibility,  become 
increasingly  sensitive  to  such  irritating  influences,  as  time  goes  on.  As  a  rule, 
the  occupational  dermatoses  do  not  occur  suddenly,  or  at  the  outset  of  expos- 
ure, but  after  a  considerable  time,  sometimes  several  years.  This  acquired 
sensitiveness  may  be  explained  either  by  the  cumulative  action  of  the  con- 
stant irritant,  or  on  the  theory  of  a  gradually  diminished  power  of  resistance. 

It  is  an  undoubted  fact  that  the  sensitiveness  of  the  skin  toward  irritants 
varies  with  the  individual.  Also  it  is  apparent  that  this  individual  sensitive- 
ness is  more  pronounced  in  the  case  of  exposure  to  some  kinds  of  irritants 
than  to  others.  There  is  comparatively  little  difference  in  the  sensitiveness 
of  various  people  to  the  action  of  thermic  irritants.  How  to  account  for  this 
varying  susceptibiHty  of  the  skin  to  reaction  from  poisons  and  irritants  is  by 
no  means  agreed  upon.  Thibierge  and  Jacquet  have  considered  that  general 
or  bodily  conditions  have  the  same  effect  in  producing  skin  inflammations  as 
local  conditions,  and  especially  in  respect  to  digestive  disturbances.  Of 
27  cases  of  trade  eczema  studied  by  Jacquet  and  Jourdanet,  in  22  there  were 
errors  in  digestion;  the  subjects  being  either  alcoholics,  addicted  to  excess  in 
tea  and  coffee,  or  accustomed  to  insufficient  mastication  and  to  hurried  eating. 
In  25  of  these  cases,  when  these  causes  were  removed  there  was  improvement. 
Darier,  also,  considers  that  alimentary  hygiene  has  a  marked  influence  on 
the  vulnerabihty  of  the  skin.  Four  patients  were  cured  or  improved  in  7 
days  by  the  treatment  of  the  digestion  without  local  treatment,  and  nine 
were  cured  or  improved  without  suppression  of  professional  contact.  On 
the  other  hand,  Herxheimer  states  that  in  a  great  many  trade  eczemas,  and 
other  chronic  eczemas,  observed  in  the  course  of  years,  no  progress  toward 
ameUoration  was  made  by  attention  to  the  diet  alone.  He  does  not  consider 
it  necessary  to  invoke  trouble  with  the  internal  organs  in  trade  eczemas,  as 
there  are  many  local  factors,  such  as  the  varying  fat  content  of  the  skin,  the 
composition  of  the  sweat,  etc.,  that  may  account  for  varying  susceptibility. 
On  the  whole,  there  is  insufficient  data  from  which  to  determine  the  under- 
lying reason  for  this  varying  susceptibility  of  the  individual.  There  is  no 
foundation  for  the  assumption  that  it  implies  a  difference  in  the  condition  of 
the  internal  organs,  or  of  the  vital  processes  in  general. 

The  number  of  different  occupations  that  have  been  found  to  be  the  cause 


356  OCCUPATIONAL  AFFECTIONS  OF  THE  SKIN 

of  cutaneous  disturbances  is  very  large.  Herxheimer  has  compiled  74 
different  "trade  eczemas"  and  asserts  that  probably  some  were  overlooked, 
while  new  ones  may  be  expected  to  arise  constantly,  with  new  methods  of 
technique.  Age  and  sex  appear  to  be  factors  of  very  httle  importance  in 
occupational  dermatoses  generally,  although  Merzbach's  figures  show  that 
the  ages  from  20  to  40  are  the  ones  in  which  subjects  are  most  likely  to  be 
affected.  In  certain  occupations,  it  is  true,  only  women  have  been  found  to 
be  affected,  in  others  only  men.  Nationality  is  not  a  factor  of  importance. 
Knowles,  from  the  investigations  alluded  to,  found  that  a  very  large  majority 
of  the  outbreaks  occurred  during  the  winter  months,  in  practically  all  of  the 
occupations  concerned;  also  that  most  of  the  cases  collated  by  him  lasted 
over  a  period  of  weeks  or  months  independently  of  the  abandonment  of  the 
irritating  occupation;  that  the  eruption  had  a  tendency  to  relapse,  and  that  a 
less  amount  of  irritation  was  needed  to  excite  the  later  attacks. 

OCCUPATIONAL  DERMATOSES,  CONSIDERED  ACCORDING  TO 
THE  VARIOUS  TRADES  AND  CALLINGS 

Housemaids  and  Houseworkers. — People  engaged  in  these  occupations 
contribute  a  very  large  number  of  cases  to  the  class  we  are  discussing.  The 
type  of  eruption  usually  presented  is  that  of  an  eczema,  most  commonly  of  the 
squamous  or  vesicular  variety,  but  not  infrequently  papular,  erthematous 
or  oozing  in  character.  In  almost  all  cases  the,  dermatitis  is  present  on  the 
hands  and  arms,  spreading  oftentimes  to  the  legs,  feet,  face  and  neck.  Ex- 
tensive eruptions  may  have  their  origin  in  this  way.  The  direct  cause  of 
most  of  these  cases  is  the  constant  use  of  water  and  soap.  Water  and  soap 
are  both  cutaneous  irritants,  withdrawing  the  protecting  fat  and  softening 
and  removing  the  outer  horny  layer  so  that  the  skin  is  deprived  of  some  of  its 
power  of  resistance  and  becomes  more  vulnerable.  Washerwomen,  who  are 
included  in  this  class,  are  especially  liable  to  a  dermatitis  of  the  hands  and 
arms  from  the  continual  immersion  of  these  parts  in  soap  and  water.  The 
strong  alkaline  soaps  that  are  used  on  account  of  their  superior  detergent 
powers  are  responsible  in  great  measure  for  these  irritating  effects.  Various 
washing  powders  and  cleansing  alkalies  are  added  oftentimes,  especially  for 
the  greater  facility  in  washing  clothes,  and  these  are  to  the  highest  degree 
irritating.  The  poor  character  of  many  of  the  soaps  is  also  responsible,  a 
free  alkali  when  present  adding  much  to  the  irritating  properties.  These 
results  from  the  use  of  soap  and  water,  so  common  in  houseworkers,  are 
often  seen  in  people  who  are  not  obliged  to  work,  but  have  acquired  the  habit 
of  constantly  scrubbing  their  hands  with  soap  and  water.  Fordyce  states 
that  nearly  one-third  of  the  occupational  diseases  seen  in  his  clinic  during  a 
year  were  in  people  whose  work  caused  them  to  employ  soap  and  water 
freely,  or  else  the  various  alkaline  cleansing  agents.  Knowles  found  that  in 
his  experience  housewives  who  had  to  do  all  of  their  own  work  on  account  of 


OCCUPATIONAL  AFFECTIONS  OF  THE  SKIN  357 

financial  reasons,  such  as  cleaning,  washing  and  cooking,  were  the  ones  most 
likely  to  be  affected  in  this  way.  Another  affection  to  which  people  of  this 
class  are  more  or  less  subject,  together  with  all  those  whose  occupations  re- 
quire them  to  stand  constantly,  is  chronic  dermatitis  of  the  lower  legs,  com- 
bined oftentimes  with  varicose  veins  and  resulting  not  infrequently  in  the 
well-known  stubborn  varicose  ulcer.  In  washerwomen,  besides  the  inflam- 
mation that  has  been  described,  a  peculiar  condition  of  the  face  is  often  met 
with.  This  is  characterized  by  the  presence  of  a  number  of  rounded,  trans- 
lucent yellowish-white  vesicles,  of  about  the  size  of  a  small  pea  on  the  average, 
which  are  called  hydrocystomata,  and  which  represent  a  cystic  condition  of 
the  sweat  ducts  of  the  middle  third  of  the  face.  These  lesions  also  occur 
sometimes  in  those  who  perspire  freely,  and  in  the  case  of  washerwomen 
are  attributed  to  the  warm  moist  atmosphere  in  which  the  subjects  work. 

Bakers. — ^A  dermatitis  of  the  hands  and  forearms  of  bakers,  caused  by 
constant  contact  of  the  skin  with  the  moist  dough,  aided  by  the  heat  of  their 
surroundings,  has  been  frequently  observed.  Knowles  remarks  that  "  bakers' 
eczema"  or  "bakers'  itch,"  as  it  has  been  called,  was  first  referred  to  by 
Willan  in  1817  under  the  name  of  psoriasis  diffusa.  Knowles  reports  that  he 
has  met  with  11  cases  of  this  affection.  Although  no  accurate  figures  are 
available,  it  is  no  doubt  true  that  a  large  number  of  cases  have  been  observed 
in  the  skin  department  of  the  Massachusetts  General  Hospital  during  the 
last  20  years.  The  lesions  present  the  appearance  of  rather  circumscribed 
crusted  patches,  often  circinate  in  shape  and  resembling  psoriasis  somewhat. 
They  are  most  common  upon  the  hands,  and  are  often  similar  in  character  to 
the  appearances  seen  in  workers  in  sugar.  Acne,  furuncles,  and  localized 
abscesses  are  said  to  be  of  frequent  occurrence  among  bakers,  the  last  two 
named  being  doubtless  from  the  abundant  opportunity  for  secondary  infec- 
tion afforded  by  the  situation  and  character  of  the  dermatitis.  It  is  quite 
unlikely  that  the  presence  of  mites  in  the  flour  is  to  any  degree  responsible 
for  the  eruption. 

Barbers. — -Barbers  and  hairdressers  are.exposed  to  much  the  same  external 
influences  as  are  washerwomen  and  houseworkers,  from  the  necessity  of 
constant  contact  of  their  hands  with  soap  and  water,  in  the  process  of  rubbing 
in  the  soap  for  shaving  and  in  shampooing  the  head  with  various  soap  prepa- 
rations. They  often  use  alcoholic  solutions  of  the  potash  soaps,  employed 
on  account  of  their  greater  detergent  qualities.  The  various  stimulating 
lotions  that  are  rubbed  into  the  scalp  are  also  often  the  cause  of  irritation, 
such  as  strong  cantharidal  preparations,  the  various  aniline  hair  dyes,  quinine 
hair  tonics,  etc.  The  resulting  dermatosis  usually  takes  the  form  of  a  papu- 
lar eczema  confined  to  the  hands,  and  especially  affecting  the  fingers,  al- 
though the  arms  also  may  be  involved.  Knowles  has  collected  15  cases  of 
this  affection.  Fordyce  has  seen  unusually  severe  forms  of  eczematous 
dermatitis  in  barbers  who  had  been  in  the  habit  of  using  aniline  hair  dyes 
on  their  customers. 


358  OCCUPATIONAL  AFFECTIONS  OF  THE  SKIN 

Workers  in  Sugar,  Chocolate  and  Candies — Confectioners. — A  dermatitis 
of  the  hands  and  arms  of  those  who  were  in  the  habit  of  handhng  sugar  was 
one  of  the  first  forms  of  trade  dermatoses  recognized.  White  says,  "The 
old-fashioned  term  'grocer's  itch'  is  rarely  applicable  in  these  days  of  refined 
and  double-refined  sugars.  Formerly,  when  brown  sugars  were  almost  uni- 
versally used  in  the  household,  it  was  employed  to  signify  an  eczema  of  fre- 
quent occurrence  upon  the  hands  of  the  grocer  who  handled  not  only  these 
but  many  other  substances  belonging  to  his  trade,  which  were  more  or  less 
irritating  to  the  skin.  What  share  the  sugar  had  in  thus  exciting  the  skin,  it 
is  impossible  to  say,  but  to  it  was  attributed  the  greatest.  These  sugars  often 
contained  an  abundance  of  mites,  but  it  is  improbable  that  they  excited  any 
irritation  by  contact." 

Eruptions  of  an  eczematous  type  on  the  hands  of  those  who  work  in  sugar 
and  candy  manufacturies  are  frequently  observed,  and  are  well  known  to  all 
dermatologists  who  have  had  experience  in  public  chnics.  The  eruption  may 
at  times  extend  to  the  arms.  Knowles  has  noted  an  outbreak  in  four  female 
candymakers  and  in  two  of  the  male  sex,  three  working  in  a  sugar  refinery, 
and  one  a  chocolate  roaster.  He  considers  it  difficult  to  determine  the  exact 
causation  in  these  cases,  but  the  trade  was  undoubtedly  responsible  for  them, 
as  the  condition  relapsed  whenever  the  subjects  resumed  their  occupation. 
At  one  time  numerous  cases  were  seen  by  the  writer  in  girls  whose  occupation 
was  to  dip  candies  in  chocolate  in  order  to  produce  a  coating  of  the  latter. 
These  eruptions  usually  took  the  form  of  a  papular  dermatitis.  As  White 
says,  another  cause  than  that  of  the  sugar  is  present  here,  viz.,  direct  heat  and 
general  high  temperature  of  the  workshops.  Remy  and  Broca  have  reported 
four  cases  of  ecthyma  of  the  arms  and  legs  in  people  who  worked  in  sugar  re- 
fineries, either  naked  or  partially  so.  These  eruptions  they  considered  due 
to  contact  with  the  sugar,  as  they  affected  the  uncovered  portions  of  the  body, 
beginning  with  a  pustule,  and  often  being  associated  with  an  eczema.  These 
cases  were  found  to  be  especially  common  in  the  workmen  who  had  recently 
arrived,  and  to  be  very  uncommon  in  those  who  practised  frequent  washing 
and  paid  strict  attention  to  hygiene.  In  all  cases  it  occurred  in  those  whose 
skins  had  been  in  contact  with  melted  sugar  or  molasses,  or  whose  trousers 
had  become  impregnated  with  these  fluids.  In  these  cases  of  molasses  workers, 
it  is  common  to  work  in  the  saccharine  fluid  up  to  the  waist.  Fordyce 
refers  to  a  personal  communication  from  Winfield  in  which  he  speaks  of  a 
dermatitis  in  sugar  refineries,  occupying  the  hands,  forearms  and  legs  and 
suggesting  scabies  somewhat. 

Poncet,  Albcrtin,  Chaussende,  and  other  French  writers  have  described 
a  form  of  inflammation  of  the  nails  occurring  in  confectioners.  This  has 
been  observed  chiefly  in  the  workmen  employed  in  the  great  factories  of 
southern  France  in  making  sugared  fruits.  The  eruption  has  been  attributed 
by  many  to  the  chemical  acids  contained  in  the  juice  of  the  fruits,  into  which 
the  hands  are  dipped;  others  consider  that  it  is  due  to  the  saccharine  solutions 


r 


OCCUPATIONAL  AFFECTIONS  OF  THE  SKIN  359 

and  that  it  is  analogous  in  its  causation  to  the  usual  "sugar  bakers'  eczema." 
There  can  be  no  doubt  that  the  cold  and  hot  water  into  which  the  fingers  are 
constantly  dipped  acts  as  a  contributing  factor,  at  least,  in  the  etiology.  The 
affection  begins  in  the  form  of  erosions  and  fissures  about  the  nail  fold,  fol- 
lowed by  inflammation,  ulceration  and  granulations,  together  with  a  sero-puru- 
lent  secretion.  The  nail  is  often  loosened  from  its  nail  bed  and  is  destroyed. 
The  course  is  very  chronic,  lasting  for  years,  with  subacute  intervals.  The 
characteristics  are :  its  affecting  a  number  of  the  nails  simultaneously,  the  dis- 
coloration of  the  nails,  the  granulations  about  the  nail  fold,  and  the  flattening 
of  the  nail  phalanx.  Poncet  considers  that  the  onychia  is  sufficiently  char- 
acteristic to  warrant  its  serving  in  legal  medicine,  as  a  means  of  identification. 
The  middle  and  ring  fingers  are  those  first  affected.  After  the  fall  of  the  nail 
the  extremities  of  the  fingers  take  on  a  characteristic  form,  a  spatulate  shape, 
which  is  lasting.  Strauss  has  reported  three  cases  of  this  affection,  together 
with  a  good  description. 

A  lymphangitis  has  been  described  by  Oliver  as  occurring  in  workers  in 
sugar  refineries,  among  the  refiners  and  molasses  stirrers.  A  slight  degree  of 
constitutional  disturbance  has  been  noted,  and  furuncles  are  sometimes  an 
accompaniment.  Gaillot  has  attributed  the  cause  of  this  lymphangitis  to  the 
staphylococcus  pyogenes  aureus  which  is  found  in  the  residue  of  the  molasses, 
acting  in  conjunction  with  the  temperature  of  the  factory  and  the  condition  of 
the  skin. 

Builders,  Masons,  Brickmakers,  Laborers. — This  class  of  people  are  sub- 
ject to  dermatoses  from  the  character  of  their  occupation,  as  well  as  from  the 
exposure  to  the  weather  incident  to  their  calling.  Excessive  cold,  beside  the 
various  degrees  of  more  or  less  generaHzed  dermatitis  that  it  may  produce,  is 
the  cause  in  many  instances  of  chilblains,  which  often  produce  much  suffering 
and  may  interfere  seriously  with  the  occupation.  In  this  connection  the 
rosacea  so  common  in  drivers,  coachmen,  and  those  whose  faces  are  much 
exposed  to  the  action  of  the  wind  and  weather,  may  be  alluded  to.  It  is  also 
true  that  much  of  this  may  be  attributed  to  the  effect  of  alcohol,  to  which  this 
class  of  people  is  notoriously  addicted.  Varicose  veins  with  their  sequel, 
chronic  ulcer  of  the  lower  legs,  is  also  a  prominent  affection  in  these  callings, 
as  well  as  in  all  others  in  which  long  hours  of  standing  at  work  are  necessary. 
Builders  and  masons  are  very  often  affected  by  a  dermatitis  of  the  exposed 
parts  of  the  body  caused  by  the  irritation  from  the  Hme  and  cement  with 
which  they  have  to  do.  Plasterers,  whitewashers,  and  paperhangers  are 
similarly  affected.  Brickmakers  are  often  affected  with  a  dermatitis  of  the 
palms. 

Tobacco  Workers. — ^Long-continued,  stubborn  eruptions  upon  the  hands 
are  observed  in  those  who  work  constantly  with  tobacco,  in  the  process  of 
cigar  making  as  a  rule.  These  eruptions  are  very  liable  to  relapse.  The 
dermatitis  has  by  some  been  attributed  to  the  irritating  effects  of  the  nico- 
tine, by  others  to  the  caustic  solutions  that  are  used  for  separating  the  tobacco 


360  OCCUPATIONAL   AFFECTIONS   OF    THE    SKIN 

leaves.  Tobacco  workers  generally  work  under  very  unfavorable  hygienic 
conditions,  and  the  heat  and  moisture  to  which  they  are  subjected  must  be 
looked  on  as  prominent  factors  in  the  etiology  of  this  dermatitis. 

Furniture  Polishers. — This  trade  lends  itself  with  a  surprising  frequency 
to  a  well-marked  and  rather  characteristic  dermatitis  of  the  hands  and  espe- 
cially of  the  fingers,  the  so-called  "  polishers'  itch."  It  is  attributed  to  methyl 
or  impure  alcohol  which  is  used  in  making  various  varnishes  and  polishes,  and 
impure  benzine  for  cleaning  purposes.  A  somewhat  characteristic  appear- 
ance is  produced  in  these  cases  from  the  staining  of  the  nails  and  skin  by  the 
preparations  used,  and  by  the  odor  that  in  recent  cases  clings  to  the  epidermis, 
sodden  and  impregnated  with  the  preparations.  Not  infrequently  the  writer 
has  noticed  a  dermatitis  of  the  face  also  in  these  cases,  of  an  erythematous 
type,  situated  especially  about  the  mouth,  nose,  and  ears,  and  of  a  peculiarly 
shining,  glistening  aspect.  Also  in  many  cases  there  has  seemed  to  be  a  con- 
dition of  general  ansemia,  and  lowered  physical  vigor.  Machinists  and  oilers 
may  also  be  similarly  affected.  Bl'aschko  states  that  before  the  introduction 
of  denatured  spirit  (i.e.,  before  1879)  there  were  very  few  skin  affections  in 
furniture  polishers.  He  refers  especially  to  troubles  with  the  eyes,  catarrh, 
and  pulmonary  affections  in  this  class  of  subjects.  After  a  careful  search  of 
the  other  substances  used  by  furniture  polishers,  Blaschko  concludes  that  the 
pyridin  used  in  denaturing  the  alcohol  is  possibly  concerned  in  the  causation 
of  the  dermatitis. 

Bartenders  and  Liquor  Dealers. — Knowles  reports  eight  cases  of  der- 
matitis of  the  fingers,  hands,  and  forearms  in  bartenders,  one  in  an  alcohol 
dealer,  and  another  in  a  brewer.  The  mechanism  is  much  the  same  as  in  the 
case  of  housemaids  and  cooks,  constant  immersion  of  the  hands  in  water 
while  cleaning  glasses  and  the  strong  soaps  used,  causing  a  dermatitis  of  the 
hands  and  forearms  that  is  often  very  intractable,  especially  if  the  occupation 
is  persisted  in. 

Printers  and  Workers  in  Metals  and  Minerals. — Numerous  instances  of 
dermatitis  in  workers  at  these  trades  have  been  reported,  and  are  commonly 
met  with  in  dermatological  clinics.  Knowles  records  eight  cases  in  printers, 
two  in  typesetters,  one  in  a  press-room  worker,  one  in  a  handler  of  the  dye 
presses,  one  in  an  architect,  one  in  a  draftsman,  and  one  in  a  newspaper 
seller.  He  says  further:  "The  helper  around  a  type  foundry  is  apt  to  have  an 
outbreak  because  of  the  irritating  oils  he  is  forced  to  handle.  The  electro- 
typers  handle  lye  to  wash  off  the  forms  because  of  the  graphite  and  the  dust. 
They  take  a  mould,  consisting  of  plumbago  and  wax,  and  place  it  in  a  wash  of 
bluestone  and  muriatic  acid,  an  electric  current  is  then  turned  on,  and  a  cop- 
per coating  is  formed  on  this  wax  'shell.'  This  shell  remains  in  the  solution 
for  from  40  to  45  minutes.  This  mould  is  then  placed  in  a  machine  and 
lead  is  run  in  on  it,  the  wax  is  then  removed  and  the  electrotype  is  finished. 
Stereotypers  use  a  lead  mould  without  the  copper  surface.  The  compositors 
handle  only  gasoline  or  benzine  to  clean  the  type.     The  eruption  is  therefore 


OCCUPATIONAL  AFFECTIONS  OF  THE  SKIN  36 1 

more  apt  to  occur  in  the  electrotypers,  the  stereotypers,  the  helpers  in  the 
foundry  and  in  the  makers  of  the  moulds  than  in  the  compositors." 

Zellner  and  Wolff  report  that  there  have  been  a  great  many  cases  of  skin 
affections  of  very  similar  character  occurring  during  the  year  1912  among 
printers  employed  by  Berlin  newspapers.  The  first  appearances  were  those  of 
a  subacute  dermatitis  of  the  hands  and  forearms,  somewhat  artificial  in  type. 
It  was  found  upon  enquiry  that  the  workmen  themselves  attributed  these 
affections  to  certain  substitutes  for  the  oil  of  turpentine,  which  had  heretofore 
been  used  for  the  purpose  of  cleaning  type.  It  is  stated  that  of  late  benzine, 
lye,  petroleum  and  certain  kinds  of  pine  oil  have  been  used  as  cheap  sub- 
stitutes for  turpentine  oil  in  removing  the  ink  from  printers'  forms.  These 
substances  are  either  directly  poisonous  to  the  skin  themselves  or  contain  ir- 
ritating impurities.  An  inferior  benzine,  which  it  has  been  found  is  often  used 
as  a  substitute  for  turpentine  oil  is  decidedly  irritating  to  the  skin.  This  sub- 
stance is  also  being  used  in  certain  cheap  kinds  of  paint.  Thirty-seven  sam- 
ples of  these  substances  used  for  cleaning  were  analyzed,  with  the  result  that 
32  or  87  per  cent,  of  them  were  found  to  be  harmful,  and  a  return  to  the  use  of 
a  high-grade  oil  of  turpentine  is  therefore  considered  imperative  from  the 
point  of  view  of  the  workmen's  health.  As  illustrating  the  poisonous  char- 
acter that  may  be  present  in  some  grades  of  benzine,  the  testimony  of  Dr. 
Oestreicher  of  Berlin  is  adduced,  who  has  seen  eczema  caused  by  wearing 
gloves  that  had  been  cleansed  by  benzine,  and  he  further  states  that  harmful 
skin  effects  have  been  caused  by  cleaning  the  skin  with  benzine  before  opera- 
tions, and  also  by  using  this  substance  to  remove  surgical  and  dermatolog- 
ical  plasters. 

Workers  in  metals  and  minerals,  especially  those  engaged  in  the  silver  and 
electrotyping  trades  are  very  subject  to  a  dermatitis  of  the  hands  and  fore- 
arms. Hall,  quoted  by  Knowles,  has  described  the  mechanism  by  which 
workers  in  these  trades  acquire  an  eruption  of  the  type  of  a  papular  or  papulo- 
vesicular eczema.  The  goods  are  cleaned  by  means  of  a  revolving  brush,  on 
which  sour  beer  drops  from  a  trough  above,  and  the  liquid  from  this  revolving 
brush  is  splashed  upon  the  hands,  forearms  and  sometimes  faces  of  those 
engaged  in  the  work,  acting  thus  as  a  more  or  less  acute  cutaneous  irritant. 
The  same  writer  describes  an  outbreak  of  dermatitis  on  the  hands  and  arms  of 
polishers  and  burnishers  of  silver,  where  the  irritation  is  due  to  the  "rouge" 
used  for  burnishing,  this  so-called  "rouge"  being  a  mixture  of  "quicksilver," 
iron  and  wax.  There  are  various  grades  of  this  "rouge,"  the  coarser  variety 
showing  greater  powers  of  irritation.  Bichromate  of  potash  is  said  by 
Crocker  to  be  used  by  French  polishers  and  to  be  productive  of  a  dermatitis 
frequently.  The  cyanide  of  potash  is  also  used  for  cleaning  silver  and 
gold,  and  may  produce  cutaneous  trouble.  Knowles  cites  several  cases 
in  point. 

Dyers  and  Aniline  Workers,  Dressmakers  and  Photographers. — For  years 
severe  cases  of  dermatitis  have  been  noted  in  dyers  and  those  employed  in 


362  OCCUPATIONAL  AFFECTIONS  OF  THE  SKIN 

establishments  for  the  manufacture  of  aniUne  colors.  Compounds  of  arsenic, 
mercury  and  chromium  have  been  used  in  making  these  briUiant  dyes  from 
coal  tar — substances  that  are  of  themselves  powerful  cutaneous  irritants, 
and  are  to  be  regarded  as  in  some  measure  responsible  for  the  dermatitis  com- 
mon in  those  engaged  in  this  trade.  Bichromate  of  potash  when  apphed 
to  the  skin  produces  an  eruption  of  papules  and  pustules,  and  later  deep 
sloughs  and  ulcers.  Hence  those  workmen  who  use  this  substance  in  their 
trade — dyers,  electricians,  photographers,  etc. — often  exhibit  deep  and 
painful  ulcers  of  the  hands  and  arms.  Harrington  has  published  the  case 
of  a  capmaker  who  was  poisoned  on  the  face,  neck  and  hands  after  cutting 
up  a  piece  of  dark  blue  cloth  for  boys'  caps.  Analysis  showed  the  presence 
of  a  large  amount  of  chromium.  Two  years  afterward  a  similar  eruption 
appeared  after  dusting  and  packing  away  the  same  unmade  caps.  Poison- 
ing from  the  aniline  dyes  and  bichromate  of  potash  is  by  no  means  confined 
to  those  working  in  these  substances.  Numerous  instances  occur  of  varying 
grades  of  dermatitis  in  the  wearers  of  stockings,  gloves,  caps,  underwear 
and  shoes  which  have  been  dyed  in  this  manner.  White  reports  several 
cases  of  deep-seated  dermatitis  produced  by  gloves  and  stockings  of  quiet 
colors  that  may  have  been  due  to  the  presence  of  chrome  mordants.  Other 
instances  of  analogous  methods  of  poisoning  are  in  those  who  cut  paper 
flowers  and  patterns  from  paper  impregnated  with  aniline  dyes,  upholsterers, 
milliners  and  dry-goods  clerks,  shirt-makers,  etc.  Aurantia  or  hexanitro- 
phenylamine  is  a  dye  that  has  often  been  used  for  coloring  cheap  yellow 
leather  shoes.  Crocker  states  that  those  who  work  with  it  are  liable  to  a 
severe  dermatitis  of  the  hands,  as  the  liquid  is  sponged  on  to  the  leather  to 
be  dyed. 

Among  photographers  numerous  instances  of  dermatitis  have  been  ob- 
served which  were  attributed  to  bichromate  of  potash,  and  Richardson  of 
London  has  described  these  cases  under  the  title  of  "the  bichromate  disease." 
Beers  reports  cases  of  dermatitis  among  photographers  due  to  the  irritating 
effects  of  metal.  Knowles  produced  a  series  of  four  photographers  and  one 
photo-engraver  afflicted  in  this  way,  and  has  also  referred  to  the  case  of  a 
moving-picture  operator  poisoned  from  handling  the  films,  carbon,  and 
cement. 

Rident  has  noted  cases  among  the  linen-dyers  in  the  cloth  manufactories 
of  Elbeuf  who  dip  the  linen  in  a  bichromate  solution.  As  a  rule,  after  work- 
ing from  5  to  6  weeks  with  the  hands  immersed  in  this  solution,  redness, 
vesiculation  and  oozing  of  the  backs  of  the  hands  follow. 

The  dermatitis  that  occurs  upon  the  hands  and  forearms  of  tanners 
may  be  alluded  to  in  this  place;  this  is  due  to  the  chemical  process  through 
which  the  hide  and  leather  are  passed.  Knowles  thinks  that  the  bath  of 
bichromate  of  potash  and  muriatic  acid  in  which  the  hides  are  placed,  and 
in  which  the  workmen's  hands  remain  for  a  considerable  time,  is  the  cause 
of  the   dermatitis.     The  eruption   from  this  cause   may  be   quite  long   in 


OCCUPATIONAL  AFFECTIONS  OF  THE  SKIN  363 

duration,  compelling  the  workmen  to  suspend  work  either  temporarily  or 
permanently. 

Blaschko  has  described  the  appearances  of  the  dermatitis  in  anihne  workers 
as  of  manifold  character  and  of  very  quick  onset  often.  He  says  the  eruption 
is  so  typical  that  a  diagnosis  of  the  trade  may  be  made  from  the  appearances, 
the  backs  of  the  hands  being  much  swollen,  tinged  here  and  there  with  dye, 
with  intervening  eczematous  plaques,  Hyperhidrosis  of  the  palms  (Grand- 
homme)  has  also  been  emphasized.  The  afifection  is  often  made  worse  by 
the  means  used  for  getting  off  the  dye,  chloride  of  sodium  and  chloride  of  lime, 
the  use  of  the  latter  substances  being  partly  responsible  for  the  eczema. 

Workers  in  Chemicals  and  Drugs,  Arsenic,  Chlorine. — Those  who  handle 
chemicals  constantly  are  naturally  subject  to  dermatitis  of  the  hands  from 
the  irritation  due  to  the  contact.  Chemists  are  very  frequently  annoyed  by 
obstinate  eczemas  and  are  often  obliged  to  suspend  or  abandon  their  occupa- 
tion temporarily.  Oftentimes  an  intense  susceptibility  is  acquired — a  state 
of  anaphylaxis— to  such  a  degree  that  a  very  small  amount  of  exposure  will 
call  forth  an  outbreak.  Sometimes  chemists  are  very  susceptible  also  to  the 
fumes  of  various  chemicals.  The  face  is  naturally  affected  very  frequently 
from  contact  with  the  fumes.  Fordyce  has  several  times  seen  a  similar 
anaphylactic  condition  from  formalin  in  laboratory  workers.  In  all  of  these 
cases  the  action  of  the  chemical  is  undoubtedly  increased  by  the  constant 
immersion  of  the  hands  in  liquids,  and  by  the  use  of  strong  soaps  and  alkalies 
in  the  process  of  cleansing. 

Arsenic,  on  account  of  its  wide  use  in  the  arts,  is  a  frequent  cause  of  der- 
matitis. Preparations  of  arsenic  have  been  used  as  pigments  in  the  prepara- 
tion of  wall-papers,  and  of  colored  paper  for  other  purposes,  in  printed  and 
dyed  cloths  for  garments  and  artificial  flowers,  in  combination  with  aniline 
and  other  dyes,  as  preservatives  of  sizings  and  pastes,  and  for  curing  hides 
and  bird  skins.  James  C.  White  in  his  monograph  on  Dermatitis  Venenata 
enumerates  these  various  occupations  in  which  arsenic  is  used,  and  states 
that  the  workmen  engaged  in  manufacturing  and  those  manipulating  these 
products  are  subject  to  a  great  variety  of  inflammatory  processes  of  the 
skin.  An  erythema  is  the  first  and  mildest  grade  of  inflammation  produced 
by  the  action  of  arsenic  on  the  skin,  which  is  quickly  followed  by  papules, 
vesicles  and  pustules.  A  further  development  is  the  formation  of  char- 
acteristic ulcers,  round,  of  a  grayish  or  reddish  moist  base,  and  sometimes 
surrounded  by  a  dense  induration.  These  may  be  quite  deep  and  painful, 
and  are  commonly  seated  upon  the  hands,  especially  about  the  nails,  and  the 
forearms,  parts  which  come  directly  into  contact  with  the  arsenic.  The 
face,  especially  the  regions  of  the  lips  and  nose,  behind  the  ears,  about  the 
neck,  the  scrotum  and  surfaces  of  the  thighs  adjoining,  and  the  toes  are 
other  parts  frequently  affected.  "Arsenic  pock"  is  a  name  that  has  been 
given  to  arsenical  ulcers  of  the  hands  in  color  workers.  The  dermatosis 
that  frequently  occurs  on  the  hands  of  furriers,  especially  of  those  who  are 


364  OCCUPATIONAL  AFFECTIONS  OF  THE  SKIN 

engaged  in  handling  dyed  furs  of  an  inferior  grade,  has  been  attributed  to 
the  sulphide  of  arsenic  that  is  used  with  lime  in  the  curing  of  the  fur.  White 
has  reported  cases  of  arsenical  dermatitis  on  the  hands  of  taxidermists  in 
whom  the  typical  ulcerations  about  the  nail  were  developed  in  a  marked  way. 
He  records  the  case  of  a  man  who  suffered  from  a  severe  dermatitis,  so  that 
the  eyes  were  closed,  and  there  was  present  considerable  constitutional  dis- 
turbance. It  was  found  that  he  had  been  engaged  for  3  days  previous 
to  the  cutaneous  appearances  in  fastening  pieces  of  white  webbing  into 
sample  books,  the  paper  linings  of  which  were  covered  with  green  arsenical 
pigment  as  determined  by  chemical  analysis. 

White  says  (Dermatitis  Venenata,  1887):  "Chlorine  gas  acts  as  an  irri- 
tant upon  the  skin,  producing  prickling  and  redness  when  held  in  contact 
with  it,  and  sometimes  an  eruption  of  papules  and  vesicles.  Chlorinated 
soda  and  chlorinated  lime  solutions  occasionally  cause  a  mild  degree  of  in- 
flammation, erythematous  and  papular  in  character,  in  workmen  employed 
in  bleacheries,  paper  mills,  etc." 

Herxheimer  described  (1899)  for  the  first  time  an  affection  which  he  called 
chlorine  acne,  which  gave  rise  to  numerous  publications  confirming  his  ob- 
servations but  disagreeing  as  to  the  etiology  and  nomenclature.  It  is  ob- 
served in  electrochemical  establishments  among  workers  in  rooms  in  which 
free  chlorine  is  obtained  from  chloride  of  potash  by  electrolytic  decomposi- 
tion. Hence  it  was  concluded  that  this  acne  was  caused  by  the  chlorine, 
analogously  to  that  produced  by  bromine  and  iodine,  being  breathed  in  and 
then  excreted  by  the  sebaceous  glands.  Doubt  was  thrown  on  this  view 
later  by  the  fact  that  a  similar  affection  was  not  observed  in  establishments 
in  which  chlorine  was  generated  by  other  than  electrolytic  means.  Kaposi 
suggested  that  it  was  a  tar  acne,  and  this  view,  although  at  first  rejected, 
has  since  attained  much  prominence,  the  direct  agent  being  paranitrochlor- 
benzol  which  is  generated  in  the  electrolytic  process. 

The  constant  feature  of  this  affection  is  the  comedo,  of  the  type  common 
in  acne  vulgaris.  At  the  start  it  is  seen  on  the  central  portion  of  the  face 
alone,  but  later  it  appears  on  the  ears,  neck,  trunk  and  extremities,  often  in 
great  numbers.  With  this  comedo  formation  there  is  associated  an  eruption 
of  acne  lesions  often  attaining  a  large  size,  and  presenting  the  appearance  of 
sebaceous  cysts.  These  lesions  develop  very  rapidly,  the  affection  reaching 
its  full  extent  in  a  few  weeks  usually,  and  then  remaining  stationary  for  a 
long  time,  even  if  the  patient  has  abandoned  his  work.  Complete  healing 
is  the  final  result.  Anatomically  the  lesions  do  not  differ  from  those  of  ordi- 
nary acne  and  comedones.  They  differ  clinically  from  these  affections  by 
their  extension  over  the  body  generally.  The  affection  is  painless  and  with- 
out influence  on  the  general  health.  It  has  seemed  to  be  more  common  in 
summer  than  in  winter. 

Wood  Workers. — A  number  of  species  of  wood  handled  in  the  different 
trades  have  been  shown  to  be  poisonous  to  the  skin  of  those  working  with 


OCCUPATIONAL  AFFECTIONS  OF  THE  SKIN  365 

them.  These  for  the  most  part  are  the  foreign  species,  satinwood,  teak- 
wood,  ebonywood,  etc.  Epidemics  of  dermatitis  from  satinwood  have  been 
reported  by  Cash  as  occurring  in  the  shipyards  on  the  Clyde,  and  the 
East  Indian  satinwood  is  regarded  as  more  irritating  than  the  West  Indian 
variety.  The  alkaloid  chloroxylonine  which  the  satinwood  contains  is  re- 
garded as  the  active  agent,  but  Knowles  found  that  the  local  application  of 
East  Indian  satinwood  dust  caused  the  eruption  in  a  person  who  had  pre- 
viously been  poisoned  by  contact  with  chloroxylonine.  The  unprotected 
portions  of  the  skin — the  hands,  wrists,  face  and  ears — are  the  parts  most 
frequently  affected.  Crocker  has  recorded  cases  of  dermatitis  in  flute 
makers  who  use  cocuswood,  due,  he  thinks,  to  a  resin  in  the  wood,  which 
belongs  to  the  family  euphorbiaceae.  Horand  describes  under  the  title 
"mains  de  crocodile"  a  dermatosis  observed  in  workers  in  chestnutwood, 
which  begins  as  an  erythema  and  ends  in  a  hyperkeratosis. 

Flax  and  Linen  Workers. — Purdon  (quoted  by  White)  described  in  1875 
a  peculiar  form  of  acne  on  the  forearms  of  workers  in  the  linen  mills  of  Belfast, 
Ireland.  The  young  girls  who  removed  the  bobbins  from  the  machinery  and 
the  spinners  were  those  chiefly  attacked.  The  arms  were  the  parts  most 
affected;  next,  the  face,  owing,  it  was  thought,  to  wiping  the  face  with  the  oily 
hands.  The  eruption  was  of  a  papulo-pustular  type,  with  a  shotty  feel  in  its 
early  stages,  and  resembled  smallpox  somewhat. 

Leloir  in  1885  reported  a  skin  affection  in  flax  spinners  in  Lille.  The  erup- 
tion was  situated  mostly  on  the  hands,  and  especially  on  the  palms,  more 
commonly  the  left  one,  and  was  peculiar  to  those  who  worked  with  damp 
linen.  The  hands  of  these  workmen  were  kept  constantly  moist  with  the 
hot  water  from  a  trough  through  which  the  threads  were  made  to  pass  for 
the  purpose  of  cleansing  the  flax,  and  in  this  way  the  hands  became  covered 
with  a  mucilaginous  coating,  which  was  found  to  contain  butyric  and  lactic 
acids  combined  with  carbonate  of  lime  in  solution.  The  dermatitis  was  of 
an  erythematous,  vesicular  and  squamous  type. 

White  observes  that  in  the  cases  of  Purdon  and  Leloir  the  poisonous  action 
cannot  be  ascribed  with  certainty  to  the  flax  alone,  as  there  are  other  irritat- 
ing factors  present.  Thorough  enquiries  made  by  White  of  the  proprietors 
and  managers  of  flax  mills  failed  to  discover  any  irritating  properties  in  the 
flax  itself. 

In  1889  Leloir  described  an  epidemic  of  folliculitis  and  perifolliculitis  in 
spinners.  The  place  of  prominence  was  the  extensor  surface  of  the  lower 
limbs,  especially  where  the  wet  trousers  came  into  contact  with  the  skin.  It 
is  rare  that  it  affects  the  upper  limbs  as  the  workmen  usually  work  without 
covering  the  arms,  and  it  is  characterized  clinically  by  papules  and  papulo- 
pustules which  may  attain  a  considerable  size.  The  pruritus  may  be  quite 
severe.  Leloir  considers  that  the  affection  is  due  to  the  irritating  oil  with 
which  the  looms  are  impregnated.  The  location  is  explained  by  the  soaking 
of  the  trousers  in  the  oil  and  by  wiping  the  hands  on  the  trousers.     The  sub- 


366  OCCUPATIONAL  AFFECTIONS  OF  THE  SKIN 

jects  affected  were  usually  males,  although  some  cases  were  observed  in 
females  when  a  thin  closely  fitting  petticoat  was  worn.  Leloir  pointed  out 
the  aid  that  this  dermatosis  may  be  in  legal  medicine.  He  estimated  that 
from  5  to  8  per  cent,  of  the  workmen  were  subject  to  this  affection. 

Knowles  has  seen  outbreaks  of  dermatitis  in  five  workmen  in  a  cotton 
mill,  four  workmen  in  woolen  mills,  and  four  cases  in  weavers.  He  points  out 
the  fact  that  the  dye  houses  connected  with  the  mills  are  much  more  apt 
to  be  the  seat  of  an  outbreak  than  the  mills  proper. 

White  refers  to  an  instance  of  a  rash  reported  to  him  as  occurring  among 
workers  in  jute.  There  is  also  a  German  account  of  an  eczema  of  the  hands 
and  arms  prevalent  in  jute  mills,  attributed  to  the  oil  with  which  the  fibers 
are  saturated  in  order  to  work  them. 

Oliver  has  published  photographs  obtained  from  Dr.  Gilbert  of  Belgium, 
showing  varying  degrees  of  erosions  on  the  palms  of  workers  in  flax,  especially 
the  female  workers,  due  to  the  frequent  contact  of  the  hands  with  the  irritat- 
ing material  contained  in  the  liquid  for  spinning. 

Tar,  Paraffine  and  Petroleum  Workers. — The  various  preparations  of  tar 
have  been  used  from  very  early  times  quite  extensively  in  the  treatment  of 
skin  diseases.  The  indications  for  this  group  of  preparations  are  in  general 
the  relief  of  pruritus  and  a  diminution  of  inflammatory  infiltration  and  hyper- 
keratosis—what  has  been  termed  a  reducing  action.  Two  forms  of  derma- 
tosis may  be  produced  by  the  pathological  action  of  tar.  One  is  a  diffuse 
dermatitis,  often  accompanied  by  much  burning  and  itching  and  which  may 
merge  into  a  long-continued  eczema.  The  other  form  is  an  acniform  inflam- 
mation of  the  follicles,  the  mouths  of  the  follicles  being  often  sharply  defined 
by  a  black  stain  of  dried  tar,  so  that  the  appearance  of  comedones  is  simulated. 
Oftentimes  these  black  comedo-like  lesions  are  surrounded  by  an  inflamma- 
tory border,  and  in  this  way  the  "tar  acne"  is  produced.  In  some  cases  the 
comedo-like  appearances  are  present  without  any  inflammation  of  the  fol- 
licles. This  tar  acne  has  sometimes  been  seen  in  workmen  who  are  employed 
with  machinery  which  has  been  lubricated  with  tarry  compounds,  and  when 
the  air  of  the  workshop  is  filled  with  the  vapor  of  tar.  In  some  cases  this  tar 
acne  changes  into  a  more  diffuse  form  of  dermatitis,  of  an  eczematous  nature, 
which  has  been  called  "  tar  itch."  In  still  other  cases  workers  in  coal-oil,  and 
tar  products  generally,  have  developed  indurated  plaques  and  hyperkeratoses 
and  multiple  papillomata  which  have  in  turn  degenerated  into  malignant 
growths. 

White,  writing  in  1887,  states  that  while  it  has  been  reported  that  work- 
men in  petroleum  suffer  from  a  scarlatinoid  eruption  or  from  furuncles  on 
exposed  parts  of  the  skin,  the  crude  petroleum  itself  cannot  have  very  irritat- 
ing properties,  as  it  has  been  used  for  years  in  considerable  quantity  for  the 
destruction  of  scalp  and  pubic  lice,  without  causing  a  dermatitis.  He  has  seen 
teamsters,  who  were  engaged  in  carrying  the  crude  oil  from  the  railroad  tank 
to  the  refining  factories,  wash  their  faces  and  hands  in  a  bucket  of  the  oil.     He 


OCCUPATIONAL  AFFECTIONS  OF  THE  SKIN  367 

thinks  it  probable  that  the  poisoning  arises  from  contact  with  some  of  the 
numerous  products  obtained  by  the  various  processes  there  employed,  and 
not  from  the  crude  oil. 

Lewin  in  1888  published  an  elaborate  article  on  general  and  cutaneous 
poisoning  by  petroleum.  He  made  a  trip  to  America  and  saw  cases  of  skin 
affections  in  the  Atlantic  Refining  Company,  which  had  their  seat  especially 
on  the  upper  leg,  knee,  and  arms.  There  were  often  acniform  lesions  on  the 
arms,  as  well  as  large  furuncles  with  inflammatory  appearances  in  the  vicin- 
ity. He  found  that  it  was  the  heavier  oils  that  caused  the  trouble,  for  no 
affections  of  the  skin  were  found  among  those  who  worked  with  the  hghter 
oils. 

Derville  and  Guermonprez,  writing  in  1890,  report  that  they  examined 
between  400  and  500  workers  in  petroleum  refineries,  with  the  result 
that  they  found  only  four  affected  with  papillomata,  and  these  were  the 
men  who  were  engaged  in  cleaning  the  apparatus  used  in  the  last  distillation 
of  the  petroleum.  The  clothing  becomes  saturated  with  the  oily  substance, 
and  exhales  a  penetrating  odor  of  petroleum.  The  forearms  and  hands  are 
most  frequently  attacked,  although  other  parts  may  be  affected,  such  as  the 
eyelid  and  scrotum.  The  warty  growths  are  of  a  very  variable  size,  and 
seated  upon  a  deeply  pigmented  skin  which  is  dry  and  often  spotted  with 
white  cicatrices. 

Mackenzie  has  described  similar  appearances  in  a  man  30  years  of  age 
who  worked  in  creosote.  In  this  case  the  forearms  and  backs  of  the  hands 
showed  numerous  comedones  between  which  were  warty  elevations  as  large  as 
a  pea  in  some  instances.  There  were  similar  lesions  on  the  scrotum.  The 
microscope  showed  epithelial  degeneration. 

Piff'ard  quotes  Ogston  as  describing  a  dermatitis  of  the  hands,  wrists,  feet 
and  legs  in  the  workmen  engaged  in  working  crude  parafiine.  The  eruption  is 
composed  of  bright  red  nodules  about  the  follicles,  and  these  nodules  gradu- 
ally subside  leaving  the  mouths  of  the  follicles  dilated  and  filled  with  black 
dots.  The  backs  of  the  hands  are  most  severely  affected,  and  in  exagger- 
ated cases  present  a  peculiar  honeycombed  appearance,  due  to  thick  clusters 
of  distended  hair  follicles. 

Florists,  Gardeners,  and  Those  who  Handle  Plants  and  Flowers. — At 
the  time  of  the  publication  of  his  valuable  monograph  on  Dermatitis  Vene- 
nata in  1887,  White  estimated  roughly  that  about  60  native  plants  or  those 
introduced  into  the  United  States  were  capable  in  some  way  of  injuring  the 
skin.  Since  then  he  himself  and  others  have  added  considerably  to  this  list. 
Among  the  most  common  of  the  plants  that  call  forth  a  reaction  in  the  human 
skin  are  poison  ivy,  poison  sumach,  poison  oak,  the  two  species  of  nettle, 
Japanese  primrose,  etc.  Gardeners  and  florists  suffer  frequently  from  a 
dermatitis  of  the  hands  and  arms,  extending  often  to  the  face  and  other  parts 
of  the  body,  from  handling  and  working  among  these  plants.  A  pretty  seri- 
ous acute  dermatitis  may  be  present,  such  as  all  are  familiar  with  in  intense 


368  OCCUPATIONAL  AFFECTIONS  OF  THE  SKIN 

cases  of  poisoning  from  ivy,  extending  in  some  cases  over  a  large  part  of  the 
body  and  causing  great  oedema  and  discomfort. 

Lacquer  is  obtained  from  the  juice  of  a  species  of  rhus  in  Japan,  closely 
allied  to  our  native  plant.  White  says  that  the  history  of  the  preparation 
of  this  celebrated  varnish  of  Japan  and  its  effect  on  the  workmen  engaged  in 
its  manufacture  and  use  are  very  little  known.  Incisions  are  made  in  the 
bark  extending  about  one-quarter  of  the  trunk's  circumference  and  just  deep 
enough  to  reach  the  wood.  The  clear  sap  which  flows  out  becomes  rapidly 
darker  on  exposure  to  the  air,  and  gradually  takes  on  a  dark  brown  almost 
black  color.  The  sap  is  preserved  in  bamboo  tubes,  to  keep  it  from  turning 
black.  It  is  shown  by  older  writings  that  those  who  worked  with  this  sap  were 
frequently  poisoned.  White  found  that  the  embossed  Japanese  wall-papers 
that  are  used  in  our  houses  have  produced  severe  inflammation  on  the  hands  of 
the  hangers,  in  consequence,  he  assumes,  of  the  abundant  lacquer  with  which 
they  are  covered.  Allen  of  Korea  has  reported  that  many  foreigners  as  well 
as  natives  in  the  East  are  affected  with  "varnish  poisoning,"  which  is  in  some 
cases  so  pronounced  that  the  person  cannot  pass  a  furniture  shop  where 
articles  are  being  varnished  without  being  poisoned.  This  susceptibility  is 
more  pronounced  during  the  rainy  season. 

Citrus  vulgaris,  the  bitter  orange,  is  largely  used  for  the  manufacture  of 
marmalade  in  Florida  and  in  some  parts  of  Europe.  Bazin  described  the 
occurrence  of  a  dermatitis  of  the  face  and  upper  extermities  in  workmen 
employed  in  peeling  this  fruit  in  France.  The  left  hand,  in  which  the  fruit 
is  held  while  being  cut,  is  especially  affected.  In  the  United  States  it  is 
stated  that  persons  employed  in  manufacturing  oil  of  orange  peel  suffer 
greatly  from  erythematous,  papular,  and  vesicular  eruptions  of  the  skin, 
especially  of  the  hands.  White  states  that  inquiry  among  the  large  orange 
growers  of  southern  California  fails  to  discover  the  occurrence  of  poisoning 
in  those  who  handle  the  fruit.     Marmalade  is  not  commonly  made  there. 

Vanilla  comes  from  the  bean  of  a  pla^it  cultivated  in  Mexico,  Central 
America,  the  West  Indies,  and  also  in  the  East.  It  grows  best  in  Mexico. 
White  reports  a  case  of  acute  dermatitis  of  the  head  and  hands  in  a  man  who 
had  been  twice  affected  in  the  same  way  since  he  had  been  engaged  in  manag- 
ing a  vanilla  commission  house.  In  the  manufacture  of  vanilla  the  beans 
are  collected,  put  through  a  "sweating"  process,  turned  frequently  under 
blankets,  and  sometimes  submitted  to  artificial  heat,  until  they  assume  a  dark 
chocolate  or  blackish  color.  In  handling  these  pods  many  of  the  workmen 
acquire  a  dermatitis  of  the  hands  and  face,  which  has  been  attributed  to  two 
causes:  first,  an  acarus,  which  is  improbable;  second,  in  the  lower  qualities  of 
pods  it  is  known  that  an  artificial  method  is  used  for  coloring  them  black,  and 
that  this  material  is  the  oil  of  the  cashew  nut  found  in  the  rind,  called  cardol. 
White  says  that  there  is  little  doubt  that  these  cases  of  so-called  vanilla 
poisoning  are  from  the  cardol  of  this  nut. 

White  was  the  first  to  call  attention  to  the  frequency  with  which  those 


OCCUPATIONAL  AFFECTIONS  OF  THE  SKIN  369 

who  handled  the  primula  obconica,  or  Japanese  primrose,  acquired  an  arti- 
ficial dermatitis  upon  the  face  and  hands.  Since  then  others  have  observed 
this  occurrence,  especially  the  English.  This  plant  was  introduced  to 
European  florists  in  1882  from  China.  The  first  case  observed  was  in  a 
florist,  who  was  attacked  at  the  same  time  during  2  successive  years,  a 
day  or  two  after  this  plant  came  into  bloom,  and  on  each  occasion  two  of  his 
assistants  were  also  affected.  A  botanist  finds  that  the  hairs  with  which 
the  leaf  and  flower  stems  are  abundantly  provided  are  easily  detached, 
pointed,  jointed,  and  contain  a  large  amount  of  silex,  and  that  none  of  the 
other  species  of  primula  are  provided  with  these  hairs;  hence  it  is  probable 
that  they  produce  the  inflammation. 

Walsh  has  described  a  dermatitis  among  flower  pickers  in  the  Scilly 
Islands,  the  so-called  "lily  rash."  The  narcissus  is  cultivated  in  great 
quantities  in  these  islands  and  exported  in  the  spring.  The  workmen  who 
cut  the  flowers  are  subject  to  an  artificial  dermatitis  of  the  hands,  arms,  and 
face;  not  all  varieties  are  said  to  be  equally  harmful,  the  most  dangerous 
being  the  "campanelle." 

An  epidemic  of  dermatitis  among  the  workers  in  rice  fields  has  been 
alluded  to  by  Mantegazza,  affecting  the  feet,  legs,  hands  and  arms.  He 
found  that  it  was  only  in  certain  fields  and  during  certain  years  that  this 
occurred,  and  attributed  it  to  a  small  plant,  covered  with  numerous  spines 
up  to  the  top,  which  he  found  in  the  fields  in  question.  These  spines  possess 
no  secretory  apparatus  that  produces  a  toxin,  but  have  a  mechanical  action, 
boring  into  the  skin  of  the  laborer  who  goes  into  the  water  and  therefore 
rubs  against  the  leaves  of  the  plant. 

Quinine  and  its  compounds  are  capable  of  setting  up  a  severe  dermatitis 
in  those  handling  them.  White  was  not  able  to  find  any  history  of  the  occur- 
rence of  inflammation  of  the  skin  from  contact  with  the  crude  cinchona 
bark  or  other  parts  of  the  tree.  Bazin  stated  that  the  workmen  employed 
in  the  principal  quinine  factories  of  France,  Germany  and  England  were 
liable  to  a  cutaneous  disturbance,  which  was  sometimes  so  severe  as  to 
cause  them  to  give  up  their  occupation.  These  accidents  are  most  common 
in  Germany  and  France.  The  workmen  affected  are  chiefly  those  who  boil 
the  bark,  those  who  convert  the  quinine  into  the  sulphate,  and  those  who 
bottle  the  sulphate.  A  simple  residence  in  the  factories,  without  being  em- 
ployed, is  sometimes  sufficient  to  cause  this  affection.  The  affection  had 
the  form  of  a  typical,  acute  artificial  dermatitis  and  was  due,  it  was  thought, 
to  quinine  emanations.  All  of  the  workmen  did  not  seem  to  be  equally 
predisposed  to  the  affection,  as  some  had  been  engaged  in  this  occupation  for 
years  with  no  ill  effect.  In  some  cases  the  subjects  seemed  to  become  habitu- 
ated to  these  influences,  and  the  attacks  gradually  ceased;  others  were  forced 
to  give  up  their  work  permanently.  White  found  that  occasional  cases 
occurred  among  the  workmen  in  American  manufactories.  Idiosyncrasy 
seems  to  play  a  more  prominent  part  in  quinine  rashes  than  in  most  others. 
24 


370  OCCUPATIONAL  AFFECTIONS  OF  THE  SKIN 

Musicians. — Stern  has  divided  the  dermatoses  of  musicians  into  three 
categories:  i.  A  sycosis  of  violinists.  He  collected  six  cases,  three  of  whom 
were  musicians,  one  a  teacher,  and  two  tradesmen,  in  which  a  sycosiform 
eruption  developed  on  the  left  half  of  the  face,  at  the  lower  boundary  of  the 
beard,  in  essentially  the  submaxillary  region,  the  part  of  the  skin  against 
which  the  violin  is  accustomed  to  press  in  playing  on  that  instrument.  2. 
An  eczema  of  flute  players,  a  moist  dermatitis  of  the  lips  and  neighboring 
parts  of  the  cheeks  and  neck.  In  one  case  the  eczema  recurred  every  time 
the  flute  playing  was  resumed.  An  instrument  maker  to  whom  the  flute 
was  submitted  said  that  it  was  made  of  "Grenadillholz,"  red  ebony-wood 
from  the  East  Indies,  and  declared  that  he  had  received  back  a  similar  flute 
from  a  musician  because  it  had  caused  a  similar  lip  affection.  3.  Lip  affec- 
tions of  trumpeters.  In  a  number  of  cases  on  the  lower  lip  near  the  middle 
a  sort  of  abortive  furuncle  occurs,  without  tenderness.  In  other  cases  he 
observed  scaling,  horny  excrescences  in  the  same  class  of  people,  appearances 
much  like  those  of  cornu  cutaneum. 

Physicians,  Surgeons,  Nurses,  Etc. — Since  the  adoption  of  the  principle 
of  asepsis,  the  use  of  various  solutions  for  the  treatment  of  the  skin  both 
of  patients  and  of  surgeons,  dressers,  nurses  and  attendants  has  developed 
many  cases  of  obstinate  dermatitis,  especially  upon  the  hands.  The 
constant  use  of  soap,  water,  corrosive  sublimate,  carbolic  acid,  strong 
alkaline  solutions,  creohn,  formalin,  etc.,  is  responsible  in  great  measure  for 
these  conditions.  The  same  conditions  are  responsible  for  a  similar  occur- 
rence in  dentists.  Several  instances  have  come  under  the  writer's  notice  in 
which  surgeons,  after  repeated  rests  from  all  irritating  work,  have  been  com- 
pelled finally  to  abandon  their  calling  on  account  of  the  lamentable  and  dan- 
gerous condition  that  their  hands  were  continually  in.  Numerous  instances 
have  also  come  under  the  writer's  knowledge  in  nurses  who  have  been  obliged 
to  give  up  their  training  and  seek  some  other  occupation.  Formalin  is  a 
very  irritating  substance,  and  the  cause  of  many  cases  of  dermatitis.  In 
some  instances  even  a  slight  exposure  to  the  fumes  will  be  sufficient  to  cause 
an  irritation  of  the  skin.  This  susceptibility  often  increases  after  several 
attacks. 

In  this  connection  it  will  suffice  merely  to  mention  the  possibilities  that 
are  offered  to  those  attending  the  sick  of  becoming  infected  with  various 
diseases.  The  numerous  cases  of  physicians  who  have  become  infected  with 
syphilis  through  a  wound  in  the  finger,  often  in  the  practice  of  obstetrics  and 
gynecology,  are  well  known.  The  form  of  tuberculosis  of  the  skin  that  has 
been  called  tuberculosis  verrucosa  cutis,  and  that  is  due  to  direct  inoculation 
of  tuberculous  virus  on  the  cutaneous  tissues,  is  seen  occasionally  in  physicians 
and  nurses,  as  well  as  in  medical  students  and  dissectors,  ward  tenders,  etc. 

Butchers,  Cooks,  and  Those  who  have  to  do  with  Animals  and  Animal 
Products. — Most  of  the  cutaneous  affections  caused  or  influenced  by  special 
occupations,  which  have  been  considered  in  the  preceding  pages,  are  a  serious 


OCCUPATIONAL  AFFECTIONS  OF  THE  SKIN  37 1 

menace  to  life  only  in  exceptional  instances  and,  as  a  rule,  when  they  become 
generalized.  Among  people  who  deal  with  animals  and  with  animal  products 
we  find  a  class  of  cases  due  to  direct  infections  that  are,  as  a  rule,  much  more 
serious  in  their  results  and  often  a  menace  to  the  life  of  the  individual. 

Pyogenic  and  Tricophytinic  Infections. — Very  numerous  instances  of  the 
pyogenic  affections  of  the  skin,  such  as  impetigo  contagiosa,  furuncles, 
carbuncles,  etc.,  are  found  in  butchers,  cattlemen  and  those  who  have  to  do 
with  dead  animal  matter.  The  opportunity  for  acquiring  these  affections  in 
the  course  of  such  occupations  is  obvious.  Tinea  tricophytina  and  allied 
forms  of  vegetable  parasites  often  are  found  in  animals,  especially  domestic 
animals.  Frequent  instances  of  contagion  from  cats  and  dogs  are  found  in 
children,  and  occasionally,  as  is  natural,  these  affections  are  transmitted  to 
dog  fanciers  and  those  who  have  the  care  of  such  animals.  Tinea  tricophy- 
tina has  been  described  as  occurring  in  nursemaids  and  in  those  who  take 
care  of  similarly  affected  children  in  institutions  and  day  nurseries.  Several 
years  ago  a  herder  from  Vermont  was  received  into  the  skin  ward  of  the 
Massachusetts  General  Hospital  suffering  from  a  very  aggravated  case  of 
tinea  of  the  beard,  so-called  parasitic  sycosis.  The  skin  of  the  maxillary 
regions  was  much  tumified  and  indurated  and  covered  with  large  nodular 
sycosiform  tumors.  It  was  ascertained  that  others  among  his  fellow- workers 
were  affected  in  a  milder  degree  with  the  same  trouble,  and  that  there  had 
been  an  epidemic  among  the  cattle  of  a  cutaneous  disturbance  causing  a  fall- 
ing of  the  hair. 

A  much  more  serious  cutaneous  infection  may  occur  in  butchers,  an  ex- 
ample of  which  was  observed  by  the  writer  in  1902.  The  subject  was  a  whole- 
sale meat  cutter,  28  years  of  age,  who  was  affected  with  a  universal  pemphigoid 
eruption  accompanied  by  fever  and  severe  constitutional  symptoms,  following 
a  cut  received  on  his  hand  in  the  course  of  his  occupation  that  had  become 
septic.  This  patient  recovered,  but  Fernet,  who  has  made  a  special  study  of 
this  subject,  finds  the  prognosis  very  grave,  most  cases  ending  fatally.  He 
collected  16  cases,  one-half  of  which  were  in  butchers;  but  in  all  of  the  remain- 
ing cases  the  occupation  was  one  that  brought  the  subject  into  contact  with 
animals  or  animal  products,  one  case  being  that  of  a  tanner,  another  that  of  a 
person  who  had  milked  some  cows  that  had  a  bullous  affection  of  the  udders 
and  teats.  Pernet's  conclusions  were  as  follows:  i.  That  there  is  a  group  of 
rare  cases  of  acute  bullous  eruption,  accompanied  by  severe  constitutional 
symptoms  and  generally  ending  fatally,  which  affects  butchers.  2.  The  dis- 
ease follows  a  wound  on  the  hands  or  fingers.  3 .  It  is  probably  due  to  a  micro- 
organism. 4.  The  same  infectious  disease  probably  occurs  in  other  persons 
who  are  brought  into  contact  with  animals  or  animal  products.  Allen  has 
reported  a  case  in  a  blacksmith. 

The  writer's  case  occurred  simultaneously  with  the  prevalence  of  an  epi- 
zootic of  "foot  and  mouth"  disease  in  New  England,  and  the  possibility  of  a 
relationship  between  the  two  affections  was  considered.     With  regard  to  the 


372  OCCUPATIONAL   AFFECTIONS   OF   THE    SKIN 

occurrence  of  foot  and  mouth  disease  in  man,  while  strictly  medical  text-books 
and  publications  contain  little  on  this  subject,  there  are  many  allusions  to  it 
in  veterinary  literature.  According  to  Nocard  and  Leclanche,  Segar  in  1765 
was  the  first  to  report  cases  of  the  infection  of  man  by  animals  from  this  source. 
Nicolaier,  in  Ebstein  and  Schwalbe's  Handbuch  der  praktischen  Medizin, 
describes  foot  and  mouth  disease  when  occurring  in  man  as  characterized  by 
fever,  constitutional  symptoms,  and  by  a  generahzed  eruption  of  vesicles  and 
pustules,  especially  marked  on  the  fingers  and  feet,  and  affecting  the  mucous 
membranes  of  the  lips,  cheeks  and  tongue,  when  the  poison  has  gained  en- 
trance in  this  way.  He  says  that  when  the  infection  has  taken  place  through 
an  abrasion  of  the  skin,  as  is  often  the  case  in  milking  or  in  slaughtering 
diseased  animals,  the  eruption  appears  first  at  the  place  where  the  poison 
entered. 

Anthrax,  glanders,  and  actinofnycosis  are  among  the  affections  that  may 
occur  in  animals  and  be  transmitted  to  man.  Anthrax  is  very  common, 
especially  in  cattle  and  sheep,  in  various  parts  of  Europe  and  Asia.  The  dis- 
ease in  man  is  most  common  in  those  who  have  to  do  with  animals  or  animal 
products,  such  as  slaughterers,  farmers,  tanners,  wool-sorters,  stevedores,  meat 
inspectors,  employees  in  brush  factories,  etc.  It  is  said  to  be  transmitted  by 
indirect  infection  more  often  than  by  direct,  often  by  means  of  flies,  or  from 
the  hair,  hides,  wool,  etc.,  of  animals  that  have  died  of  the  disease.  As  is  well 
known,  it  is  caused  by  the  bacillus  anthracis,  one  of  the  earliest  pathological 
microbes  discovered,  and  in  its  external,  most  common  form  is  characterized 
at  the  point  of  inoculation  by  a  pustule,  which  rapidly  changes  into  a  cen- 
tral gangrenous  area  surrounded  by  a  brawny  swelling  covered  with  small 
vesicles  or  pustules.  By  the  time  the  central  necrosis  has  taken  place,  severe 
constitutional  symptoms  have  usually  set  in.  Ravenel,  quoted  by  Stelwagon, 
has  described  an  epidemic  of  anthrax  in  tanneries  near  Philadelphia,  in  the 
course  of  which  12  men  and  60  head  of  cattle  died  during  the  course  of  a  year, 
the  men  being  employed  in  the  tannery  as  operatives  and  the  cattle  fed  in 
pastures  through  which  ran  a  stream  polluted  with  the  refuse  of  the  tanneries. 

Glanders  is  usually  contracted  from  horses  and  is  seen  therefore  most 
frequently  in  stablemen  and  in  those  who  have  to  do  with  these  animals.  It 
may  be  acquired  through  a  break  or  lesion  of  the  skin  or  through  the  mucous 
membrane  of  the  mouth  or  nose.  In  some  instances  the  mucous  membranes 
are  the  parts  most  affected;  in  others  large  nodules,  the  so-called  "farcy- 
buds,  "  may  arise  from  infection  of  the  lymph  glands,  and  there  may  be  also 
a  thickening  of  the  lymphatic  vessels.  The  skin  eruption  is  in  general  of  a 
pustular  nature,  but  is  not  especially  characteristic  and  is  often  not  especially 
prominent  and  even  wanting.  The  nasal  discharge  may  be  very  profuse  or 
quite  moderate  and  is  due  to  ulceration  of  the  mucous  membrane,  which  may 
penetrate  to  the  bone.  A  chronic  form  has  been  described  and  its  description 
and  history  elaborated  by  Besnier.  The  constitutional  symptoms  are  usu- 
ally pronounced  and  the  mortality  is  high.     The  disease  is  usually  contracted 


OCCUPATIONAL  AFFECTIONS  OF  THE  SKIN  373 

either  by  direct  inoculation  of  the  secretions  on  a  wound  or  through  the 
mucous  membrane,  from  the  snorting  of  the  animal  affected.  Crocker  quotes 
the  case  of  a  laundress  who  was  infected  from  washing  the  clothes  of  a  coach- 
man who  had  died  of  the  disease. 

Actinomycosis  does  not  in  most  instances  affect  the  skin,  the  internal 
organs  being  the  parts  most  frequently  involved.  It  has  been  estimated  that 
the  disease  is  located  in  the  skin  in  only  about  3  per  cent,  of  the  cases  and, 
although  sometimes  primary  in  this  situation,  it  is  usually  secondary  to  inter- 
nal involvement.  The  seat  is  usually  about  the  face,  jaw  and  neck,  and  it 
has  often  been  proved  to  have  obtained  access  to  the  jaw  through  a  decayed 
tooth.  The  clinical  appearances  are  those  of  hard  nodular  swellings,  which 
develop  fistulas  discharging  pus  mingled  with  which  are  the  characteristic 
yellow  granules  of  the  ray  fungus.  This  ray  fungus  is  the  cause  of  the  affec- 
tion and  is  supposed,  although  it  has  not  been  proved,  to  flourish  on  hay,  corn 
and  straw.  At  all  events,  the  affection  is  undoubtedly  caused  by  inoculation 
of  the  ray  fungus,  and  is  most  commonly  seen  in  those  who  have  to  do  with 
cattle  and  horses,  including  farmers,  dairymen  and  millers.  It  has  been 
thought  to  have  been  acquired  by  chewing  straw,  grain  and  malt,  a  common 
practice  among  stablemen,  farmers,  dairymen,  etc.,  the  infection  probably 
occurring  by  inoculation  through  a  carious  tooth. 

Tuberculosis  in  the  form  of  tuberculosis  verrucosa,  that  has  been  referred 
to  as  occurring  among  physicians,  dissectors,  nurses,  etc.,  is  also  very  com- 
monly seen  in  butchers,  cooks,  cattlemen  and  those  who  have  to  do  with  ani- 
mals and  animal  products.  It  is  due  to  direct  inoculation  of  the  skin  with  the 
tubercle  bacillus  and  is  the  most  frequent  type  of  cutaneous  lesion  due  to  this 
cause.  The  lesion  has  also  been  called  the  anatomical  wart,  verruca  necro- 
genica,  etc.,  from  the  fact  that  it  was  first  observed  on  the  hands  of  anato- 
mists and  those  who  made  autopsies,  at  a  time  when  its  tubercular  nature  was 
unsuspected.  It  is  seated  on  the  hands  and  arms  almost  exclusively  and 
presents  the  appearance  of  a  papillomatous  nodule  with  a  rather  soft,  infil- 
trated base.  It  may  easily  assume  a  more  pustular  appearance  from  second- 
ary infection.  This  form  of  tuberculosis  is  very  slow  in  its  course,  and  the 
patches  may  remain  for  years  without  undergoing  much  change.  In  some 
cases,  however,  it  may  result  in  infection  of  the  neighboring  lymphatics  and 
in  foci  of  lupus  in  the  vicinity.  A  disseminated  tuberculosis  and  an  infec- 
tion of  the  internal  organs,  with  fatal  termination,  may  also  follow  occasion- 
ally. This  form  of  tuberculosis  has  been  seen  not  infrequently  in  those 
engaged  in  caring  for  tuberculous  patients,  especially  relatives,  where  the 
rules  of  hygiene,  so  rigorous  in  all  well-conducted  hospitals,  are  not  adhered  to. 

Erysipeloid  is  the  name  given  to  an  infection,  usually  comparatively  mild 
in  character,  that  is  acquired  by  butchers,  fish  dealers,  poultry  dealers,  and 
cooks  in  the  pursuit  of  their  occupations.  Of  the  cases  seen  by  the  writer,  in 
Boston  and  vicinity,  the  majority  were  in  people  who  handled  fish  in  some  way, 
either  as  fish  dealers,  fishermen,  or  cooks.     It  is  usually  situated  on  the 


374  OCCUPATIONAL  AFFECTIONS  OF  THE  SKIN 

fingers  and  hands  and  appears  as  a  sharply  bounded,  spreading  erythema,  not 
unlike  a  mild  form  of  erysipelas,  and  tends  to  spontaneous  disappearance 
after  a  few  weeks,  although  its  course  may  be  much  abridged  by  treatment. 
Rosenbach  has  discovered  a  micrococcus  of  the  order  Cladothrix  found  in  de-. 
composing  animal  matter,  which  has  produced  the  affection  experimentally 
when  inoculated  in  pure  culture.  He  obtained  a  pure  culture  on  gelatine 
from  a  case  of  erysipeloid  acquired  from  foul  cheese,  which  he  inoculated 
upon  his  own  arm  in  three  places.  Three  days  later  a  raised  erysipelatous 
patch  appeared  at  the  site  of  inoculation,  which  spread  peripherally. 
Gilchrist  has  recorded  329  cases,  of  which  323  were  caused  by  crab  bites  or 
lesions  produced  by  crabs.  The  cases  were  naturally  chiefly  in  those  who 
dealt  in  crabs  or  were  engaged  in  cleaning  them.  Gilchrist  and  others  in 
Baltimore  have  totally  failed  in  their  attempts  to  find  a  causative  organism, 
nor  were  they  able  to  produce  the  affection  by  experimental  inoculation. 

Miscellaneous  Occupations. — Under  this  heading  it  will  be  convenient 
to  group  a  few  observations  of  less  prominence  and  importance  than  those 
that  have  been  discussed.  The  theatrical  profession  has  been  the  subject 
of  an  article  by  Brown  entitled  "The  Theatrical  Profession  as  a  Factor  in 
the  Dissemination  of  Disease.''  Scabies,  pediculosis,  syphilis,  and  other 
contagious  cutaneous  affections  are  common  among  theatrical  troupes,  as 
the  opportunities  for  communicating  such  diseases  are  considerable.  The 
mode  of  life,  sojourn  in  cheap  hotels,  frequent  changes  of  domicile,  the  use 
of  cosmetics,  and  above  all  the  danger  of  infection  from  costumes  and  wigs 
render  such  affections  more  frequent  than  usual.  The  writer  has  had  under 
his  care  a  celebrated  actress  who  suffered  from  a  very  serious  parasitic 
affection  of  the  scalp,  attended  by  almost  complete  loss  of  hair,  which  she 
had  acquired  from  wigs  used  in  the  theatre. 

Since  the  introduction  of  the  X-ray  for  diagnostic  and  therapeutic  pur- 
poses, very  severe  and  sometimes  serious  conditions  of  the  skin  have  occurred 
in  operators  who  had  been  engaged  in  this  work  for  long  periods  of  time;  a 
persistent,  unusually  rebellious  dermatitis,  and  a  condition  of  atrophy,  telan- 
giectasis and  keratosis,  resembling  the  lesions  seen  in  the  rare  affection 
called  xeroderma  pigmentosum  and  often  followed  by  cancer,  are  not  infre- 
quently the  result  of  this  occupation.  This  subject  is  fully  treated  in  the 
chapter  on   Cancer. 

Audry  has  published  an  observation  on  a  papular  and  suppurative  lesion 
in  milkmen  which  affects  the  back  of  the  hand,  causing  it  to  become  greatly 
inflamed,  and  he  thinks  this  is  analogous  to  the  cases  published  by  Winter- 
nitz  of  nodular  lesions  on  the  hands,  forearms  and  noses  of  milkmaids. 

A  disease  of  the  nail  has  been  described  by  Gilbert  of  Belgium  in  furriers, 
•especially  those  who  scrape  rabbit  and  hare  skins  in  the  manufacture  of  arti- 
ficial furs.  The  work  of  separating  the  aponeurosis  that  occurs  on  the  under- 
surface  of  the  hide  causes  the  groove  under  the  nail  to  become  deeper,  and  the 
nail  is  subsequently  detached  from  the  finger  and  falls  off.     The  thumb  and 


OCCUPATIONAL  AFFECTIONS  OF  THE  SKIN  375 

the  middle  and  ring  fingers  of  the  right  hand  are  especially  aflfected.  This 
has  been  said  to  be  quite  common  in  the  fur  pullers  of  Belgium.  A  kera- 
tosis formation  of  the  palms  and  flexor  side  of  the  fingers  has  been  observed 
in  those  employed  in  removing  the  hair  from  hogs.  Stein  has  seen  a  similar 
appearance  in  glass  workers.  Spietschka  reports  a  peculiar  affection  of  the 
backs  of  the  hands  and  fingers  in  young  women  workers  in  enamel  manufac- 
tories, consisting  of  nodular  elevations  with  infiltrated  edges,  hollowed  at  the 
top. 

Under  the  title  "grain  itch"  Schamberg  has  described  an  affection  that 
became  quite  persistent  in  Philadelphia  in  the  spring  and  summer  of  1909. 
It  was  characterized  by  an  urticarial  eruption,  the  wheals  in  many  instances 
exhibiting  at  their  summits  a  central  pinpoint-sized  vesicle.  This  eruption 
was  usually  accompanied  by  most  intolerable  itching,  which  was  worse  at 
night,  and  mild  fever.  This  affection  was  found  to  be  especially  prevalent 
among  farmers  and  laborers  who  handle  sacks  of  wheat,  barley,  and  other 
grains,  and  to  be  due  to  a  mite,  the  Pediculoides  ventricosus,  found  in  grain 
or  straw. 

TREATMENT 

It  is  impossible  to  do  full  justice  to  the  treatment  of  the  various  pro- 
fessional dermatoses  without  discussing  at  some  length  the  methods  of 
treatment  applicable  to  a  large  number  of  morbid  cutaneous  conditions 
very  varying  in  character.  To  do  this  would  be  to  exceed  the  limits  or 
purpose  of  this  article.  With  regard  to  prophylactic  treatment  (the  most 
important  part  of  the  therapeutics  of  occupational  diseases),  the  avoidance 
of  the  exciting  cause  is  naturally  the  first  matter  that  presents  itself.  Total 
abandonment  of  the  occupation  that  has  proved  injurious  is  not  infrequently 
necessary.  In  many  instances  less  drastic  measures  may  be  sufiEicient,  and 
these  measures  naturally  vary  according  to  the  specific  occupation  and  often 
according  to  the  individual  case.  In  the  case  of  people  who  are  obliged  to 
have  their  hands  in  contact  with  water  and  soap  quite  frequently,  such  as 
housemaids,  bartenders,  etc.,  the  use  of  rubber  gloves  has  become  a  valuable 
prophylactic  aid,  now  that  these  articles  are  manufactured  so  well  as  to 
withstand  moderately  rough  usage.  In  these  cases  of  susceptibility  to  irri- 
tation from  soap  and  water,  as  well  as  in  all  other  cases  of  poisonous  irritants, 
the  application  of  a  bland,  softening  and  protective  cream  after  exposure, 
or  before  going  to  bed,  is  of  much  value.  Either  simple  cold  cream  ointment 
or  a  combination  of  cold  cream  with  a  small  proportion  of  lanolin  will  be  found 
most  serviceable.  Loose  white  cotton  gloves  worn  during  the  night  are  a 
good  substitute  for  a  protective  bandage.  In  the  cases  of  nurses,  physicians 
and  those  whose  hands  are  exposed  to  contact  with  strong  antiseptics, 
thorough  anointing  with  a  bland  cream  in  this  manner  is  most  useful  as  a 
preventive.  These  precautions  should  be  strictly  followed  as  soon  as  the 
subject  shows  a  well-defined  idiosyncrasy  to  any  form  of  irritation.     Various 


376  OCCUPATIONAL  AFFECTIONS  OF  THE  SKIN 

measures  of  protection  have  been  devised  to  suit  the  particular  kind  of  irri- 
tation   or  the  especial  work  of  the  individual.     Masks  have  been  used  in 
various  occupations  in  which  the  fumes  that  are  developed  have  proved  poi- 
sonous.    Measures  of  this  nature  have  been  employed  by  those  working, 
with  lacquer. 

The  immediate  treatment  of  the  greater  part  of  the  cases  of  occupational 
dermatoses  resolves  itself  into  an  understanding  of  the  principles  of  treatment 
of  dermatitis  generally,  since  a  dermatitis  either  of  the  type  of  dermatitis 
venenata  or  of  the  eczematoid  variety  is  most  frequently  met  with.  An 
acute  dermatitis  venenata  demands  first  of  all  the  removal  from  the  skin  of 
any  of  the  irritant  that  may  still  be  adherent.  For  this  purpose  soap  and 
water  is  often  essential,  although,  as  has  already  been  seen,  these  agents  are 
irritating  in  themselves,  and  their  vigorous  use  is  often  responsible  for  the 
aggravation  of  the  trouble.  Bran  or  starch  may  be  added  to  the  water  for 
the  purpose  of  "softening"  it,  as  in  the  case  of  infants  and  those  with  delicate 
skins,  and  the  various  superfatted  soaps,  less  irritating  on  account  of  the 
excess  of  fat  that  they  contain,  may  be  employed.  The  use  of  alcohol  and 
strong  alkalies  for  the  purpose  of  removing  stains  and  obstinately  adherent 
substances  should  be  resorted  to  as  sparingly  as  possible. 

It  is  needless  to  point  out  the  fact  that  there  is  no  form  of  internal  treat- 
ment that  can  be  regarded  as  in  any  way  specific  in  the  management  of  der- 
matitis. Each  case  must  be  treated  for  itself.  The  condition  of  anaemia 
that  is  often  seen  in  factory  operatives,  and  that  has  been  especially  referred 
to  in  the  case  of  furniture  polishers,  requires  careful  attention,  and  the  same 
may  be  said  as  to  dietary  errors,  and  especially  the  excessive  use  of  alcohol. 
The  wise  adviser  will  pay  careful  attention  to  the  correction  of  hygienic 
conditions  as  far  as  possible,  and  to  the  patient's  general  well-being. 

Locally,  in  the  acute  forms,  lotions  mildly  alkaline  and  slightly  carbolized, 
with  or  without  a  bland  soothing  powder  suspended  in  them,  and  perhaps 
with  the  addition  of  a  small  amount  of  glycerine,  are  of  great  value  at  the 
outset  on  account  of  their  antipruritic  properties,  as  well  as  their  relief  of 
the  acute  inflammation.  Where  there  is  not  a  large  amount  of  crusting,  a 
bland  dusting  powder  of  talcum,  zinc,  or  starch,  is  a  useful  application. 
Crusts,  if  thick,  should  be  softened  off  by  applications  of  oil,  or  by  moist 
compresses  continually  worn.  At  a  somewhat  later  period,  or  if  the  early 
stage  is  absent,  bland  ointments  and  pastes  are  indicated,  in  which  the  parts 
affected  are  wrapped,  with  an  outer  covering  of  soft  cotton  or  linen.  In  a 
large  majority  of  cases  of  dermatitis  from  external  irritants  these  measures 
are  sufficient  to  control  the  individual  attack  at  least,  provided  the  source 
of  irritation  is  removed.  The  more  chronic  forms  of  eczema  are,  however, 
well  represented  among  the  occupational  dermatoses.  In  these  cases  the 
more  stimulating  applications  are  to  be  resorted  to  on  the  same  principles 
and  with  the  same  regard  for  the  individual  case  as  in  eczemas  with  a  different 
etiology. 


OCCUPATIONAL   AFFECTIONS    OF    THE    SKIN  377 

As  regards  the  more  serious  affections,  such  as  those  acquired  in  handling 
animals  and  animal  products,  in  the  course  of  medical  and  surgical  attend- 
ance, etc.,  the  greatest  care  must  naturally  be  taken  to  prevent  the  entrance 
into  the  skin  of  any  foreign  matter.  On  this  account  people  engaged  in  these 
occupations  should  be  instructed  as  to  the  dangers  attendant  upon  their 
work,  the  probable  modes  of  inoculation,  and  the  importance  of  protecting 
all  wounds  or  abrasions  of  the  skin  by  some  form  of  protective  dressing. 

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1912,  No.  I. 
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1907,  page  255. 
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syph.,  1911,  page  11. 
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Jour,  of  Cut.  Dis.,  Jan.,  1913. 


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Med.  News.,  Phil.,  1888 
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1889,  XXI,  330-332. 
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demog.,  Paris,  1890,  768. 
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CHAPTER  II 
CANCER  AND  OCCUPATION.    X-RAY,  RADIUM 

BY  E.  E.  TYZZER,  M.  D.,  Boston,  Mass.,  and  THOMAS  ORDWAY.  M.  D.,  Albany.  N.  Y. 

I.  CANCER 

Definition. — The  term  cancer  may  be  used  in  two  senses:  in  its  general 
application  it  signifies  any  form  of  malignant  tumor;  in  its  restricted  and 
more  accurate  sense  it  is  synonymous  with  carcinoma,  a  malignant  epithelial 
tumor.  A  tumor  is  a  mass  of  tissue  which  arises  from  the  atypical  prolifera- 
tion of  certain  tissues  of  the  body  and  which  is  without  function.  Tumors 
which  possess  powers  of  unlimited  growth,  which  invade  and  interfere  with 
the  activity  of  normal  tissues  or  organs,  which  penetrate  the  circulatory 
system  and  thus  become  disseminated  throughout  the  body  so  that  death 
ultimately  results  are  termed  malignant.  Tumors  which  grow  very  slowly  by 
expansion  or  become  stationary,  and  neither  tend  to  invade  normal  tissues 
nor  become  disseminated  so  that  they  are  not  ordinarily  fatal,  are  termed 
benign. 

Incidence. — The  frequency  of  cancer  is  shown  by  the  fact  that  it  ranks 
fifth  in  the  list  of  causes  of  death. ^  According  to  the  mortality  statistics  of 
England  for  the  year  1909,  about  one  in  10  males  and  one  in  7  females  who 
died  at  the  age  of  35  years  or  over  succumbed  to  cancer.-  This  condition 
differs  from  many  other  diseases  in  that  it  is  almost  invariably  fatal  if  not 
artificially  eradicated.  The  cases  recorded  of  spontaneous  recovery  from 
cancer^  are  extremely  rare,  so  that  the  prognosis  of  untreated  cases  is  bad. 

Distribution. — Cancer  has  a  wide  zoological  distribution,  occurring  in 
many  different  species,  in  fact  in  representatives  of  practically  all  orders  of 
the  vertebrates.  The  greater  number  have  been  found  in  man  and  domestic 
animals  or  in  animals  living  in  captivity.  Tumors  have  been  reported,  how- 
ever, in  animals  living  in  the  wild  state  under  natural  conditions  so  that,  not- 
withstanding the  meagerness  of  such  observations,  it  is  certain  that  the 
development  of  tumors  is  not  restricted  to  the  artificial  conditions  of  domes- 
tication.*- ^  The  swellings  which  accompany  various  parasitic  infections 
in  lower  animals  are  often  reported  as  tumors,  but  the  term  tumor  is  in  such 
instances  used  loosely  to  designate  any  swelling  irrespective  of  its  character. 
The  frequency  of  tumors  varies  in  different  species,  and  some  appear  to  be 
practically  free  from  any  form  of  malignant  growth.  The  longevity  of  the 
individuals  in  each  species  should  be  taken  into  account,  however,  in  deter- 
mining relative  frequency.     Thus,  for  example,  tumors  appear  to  occur  fre- 

380 


CANCER    AND    OCCUPATION  38 1 

quently  in  short-lived  animals,  such  as  the  mouse  and  the  rat,  which  live  no 
more  than  2  or  3  years  at  the  most.  Although  statements  based  on 
statistical  studies  or  upon  personal  impressions  would  tend  to  show  that 
certain  less  civilized  races  are  relatively  exempt  from  cancer,®-  "^  such  conclu- 
sions cannot  be  accepted  until  more  systematic  clinical  and  pathological 
investigations  are  carried  out  among  wild  tribes.  It  frequently  requires 
only  systematic  search  for  a  condition  to  be  revealed  where  it  had  not  pre- 
viously been  suspected. 

Age. — The  incidence  of  cancer  increases  with  age,  especially  with  respect 
to  involution  changes  in  certain  organs.  If  the  incidence  is  represented  by 
a  curve,  we  have  in  early  life  the  deaths  from  congenital  tumors,  following 
which  there  is  a  drop  and  the  curve  remains  low  during  puberty,  rises  rapidly 
toward  the  end  of  the  reproductive  period  and  with  advanced  life  tends  again 
to  fall.  Age  then  is  of  considerable  importance  in  the  development  of  tumors. 
In  this  respect  there  is  marked  variance  from  the  definitely  infectious  dis- 
eases which  either  occur  early  in  life  or  are  more  or  less  distributed  with 
respect  to  age  incidence.  The  changes  which  take  place  in  the  skin  and  their 
bearing  on  the  development  of  skin  cancer  is  especially  important. 

Theories. — Many  theories  have  been  advanced  in  explanation  of  the 
etiology  of  cancer.  It  will  be  impossible  to  discuss  all  these  theories  within 
the  allotted  space,  and  thus  only  a  number  of  the  more  important  will  be 
reviewed.  Thiersch  and  Waldeyer^  have  presented  the  hypothesis  that 
there  exists  between  the  epithelium  and  connective  tissue  an  equilibrium 
through  which  the  growth  of  the  former  is  held  in  check.  On  the  degenera- 
tion of  the  connective  tissue  in  old  age  the  epithelium  proliferates  and  tumors 
develop  according  to  this  h}^othesis.  Cohnheim^  attached  great  impor- 
tance to  the  displacement  of  cells  or  groups  of  cells  from  their  normal  relations 
during  the  course  of  development,  the  so-called  "embryonic  rest"  theory. 
This  idea  of  the  dislocation  of  cells  has  also  been  utilized  by  Ribbert^^  in 
explaining  the  origin  of  tumors.  He,  however,  considered  other  forms  of 
tissue  dislocation  than  that  which  occurs  naturally  in  development.  He 
found  that  epithelium  implanted  in  the  connective  tissue  remained  alive  for 
a  time  and  was  capable  of  a  certain  amount  of  growth.  Although  epithelial 
cysts  could  be  formed  in  this  manner,  the  transplanted  tissue  possessed  only 
limited  powers  of  growth  and  never  resulted  in  a  tumor.  Ribbert  utilized 
the  disturbance  of  the  normal  relationship  of  tissues  in  chronic  inflammatory 
conditions  to  account  for  the  origin  of  tumors. 

The  theory  of  the  gametoid  nature  of  cancer  tissue  reached  its  greatest 
development  in  articles  by  Farmer,  Moore,  and  Walker^^  although  it  is  not 
original  with  them.  By  this  theory  the  unusual  activity  and  growth  of  tumor 
tissue  is  considered  to  be  due  to  a  process  of  fertilization  taking  place  between 
cells  of  the  somatic  tissues.  The  fusion  of  such  cells  gives  rise  to  a  sort 
of  hybrid  tissue  capable  of  active  growth.  A  support  for  this  theory  was 
claimed  in  the  presence  of  a  reduced  number  of  chromosomes  in  dividing 


382  OCCUPATIONAL  AFFECTIONS  OF  THE  SKIN 

cancer  cells,  also  in  the  morphological  similarity  of  the  chromosomes  to  those 
which  are  found  in  the  reproductive  cells.  Von  Hansemann^^  explains  this 
reduction  in  the  number  of  chromosomes  as  the  result  of  asymmetrical  mitotic 
division  and  suggests  that  with  the  loss  of  chromatin  there  may  be  also  a  loss 
of  differentiation  in  tissues,  which  he  terms  "anaplasia." 

The  view  that  cancer  develops  as  the  result  of  some  specific  infection  has 
found  many  adherents  and  through  the  employment  of  a  great  variety  of 
methods  many  different  organisms  have  been  reported  as  the  cause  of  cancer. 
None  of  these  has  found  acceptance  although  the  association  of  certain  para- 
sites with  inflammatory  conditions  which  may  be  followed  by  cancer  is  worthy 
of  further  consideration.  In  a  single  species,  the  common  fowl,  it  has  been 
demonstrated  that  tumors  may  be  produced  by  the  introduction  into  normal 
fowls  of  an  agent  which  is  readily  passed  through  a  Berkfeld  filter  and  which 
also  resists  drying  sufficient  to  kill  all  tumor  cells.  ^^  Whether  this  is  of  the 
nature  of  a  microorganism  or  of  a  chemical  substance  is  not  yet  conclusively 
shown.  Repeated  attempts  to  isolate  such  an  agent  from  mammalian  tumors 
have  invariably  failed. 

In  the  etiology  of  cancer  the  importance  of  certain  agents,  which  produce 
long-continued  injury  and  chronic  inflammation,  is  now  universally  recog- 
nized. Such  agents  demand  consideration  from  the  standpoint  of  occupa- 
tional disease  and  will  thus  be  discussed  somewhat  in  detail  later  on. 

The  Question  of  Contagion. — The  question  is  frequently  raised  as  to  the 
possible  contagiousness  or  infectiousness  of  cancer.  It  is  definitely  known 
that  cancer  may  be  transplanted  from  one  portion  of  the  body  to  another. 
This  frequently  happens  naturally  during  the  course  of  the  disease  either  by 
the  apposition  of  a  tumor  to  the  surface  of  healthy  tissue  or  by  the  trans- 
plantation of  tumor  cells  loosened  in  the  fluids  of  the  body,  and  it  may  occur 
artificially  during  surgical  operation.  Furthermore  it  would  probably  be 
possible,  at  least  in  some  instances,  to  transplant  tumor  cells  to  normal  indi- 
viduals, since  this  is  actually  done  in  the  experimental  propagation  of  tumors 
in  lower  animals.  The  danger  of  the  transplantation  of  tumor  cells  from  tumor 
patients  to  normal  individuals  is  undoubtedly  very  slight,  and  is  theoretically 
possible  only  in  instances  where  living  tumor  is  brought  into  contact  with 
abrasions  or  introduced  by  accident  through  incision  or  puncture.  There  is, 
however,  no  instance  recorded  of  the  accidental  transplantation  of  human 
tumor  to  normal  individuals  either  during  surgical  operation  or  pathological 
examination.  If  there  were  an  infectious  agent  concerned,  we  would  expect 
the  nurse  who  is  in  attendance  and  the  surgeon  who  is  frequently  operating 
on  cancer  cases  and  especially  the  pathologist  who  is  brought  into  frequent 
contact  with  tumor  tissue  to  show  a  high  incidence  of  cancer.  This,  however, 
has  never  been  demonstrated. 

The  Question  of  House  Infection. — The  occurrence  of  a  number  of  cases  in  a 
single  dwelling  or  in  a  certain  locality  has  raised  the  question  of  Iiouse  infec- 
tion.'^    It  has  been  pointed  out,  however,  that  the  so-called  "cancer  houses" 


CANCER   AND    OCCUPATION  383 

are  usually  occupied  by  individuals  of  more  than  the  average  age  of  the  com- 
munity at  large  and  are  also  explained  in  some  instances  by  cheap  rentals 
with  a  consequent  tendency  of  people  with  chronic  disease  to  gravitate  to- 
ward such  localities.  There  is  furthermore  no  evidence  to  indicate  that  the 
attendants  in  certain  hospitals,  almshouses,  and  other  institutions  where  such 
cases  are  cared  for,  show  a  higher  incidence  than  others.  When  the  frequency 
of  cancer  in  a  community  at  large  is  taken  into  account,  it  would  be  expected 
that  by  mere  chance  distribution  a  large  number  of  cases  would  occasionally 
be  grouped  in  a  restricted  locality  or  in  a  single  dwelling. 

Heredity. — In  the  consideration  of  the  part  played  by  heredity  in  the  occur- 
rence of  tumors,  it  has  become  more  or  less  of  a  dogma  in  medical  instruction 
that  heredity  is  here  of  no  significance.  This  teaching  is  based  upon  the  inves- 
tigations of  Pearson^^  and  others  and  was  made  on  the  basis  of  the  theory  of 
inheritance  which  has  never  been  successfully  applied  as  a  working  hypothesis 
and  which  is  not  recognized  at  the  present  time.  Sufficient  data  have  been 
collected  in  the  lower  animals  to  reopen  this  question,  so  that  the  subjects  of 
heredity  with  reference  to  cancer  in  human  beings  is  now  also  under  investiga- 
tion. ^^'  ^^'  ^*  Tumors  of  a  similar  nature  occur  in  closely  related  individuals 
sufficiently  often  as  to  create  the  belief  not  only  among  the  laity  but  also  in 
the  minds  of  many  physicians  that  heredity  is  of  importance.  While  the  data 
collected  up  to  the  present  time  from  animal  experimentation  is  insufficient 
to  serve  as  a  basis  for  any  sweeping  conclusions  concerning  human  inheritance, 
we  are  of  the  opinion  that  the  results  already  obtained  are  sufficient  to  call  for 
a  reconsideration  of  the  subject  of  heredity  with  reference  to  cancer. 

Hyperplasia. — While  certain  tumors  appear  to  rise  de  novo  without  the 
knowledge  of  any  preceding  abnormal  condition,  many  are  preceded  by 
conditions  which  are  of  long  standing  and  which  are  frequently  spoken  of  as 
"precancerous."'  There  are  various  agents  which  produce  unusual  growth  or 
proliferation  of  tissues.  Such  tissues  during  proliferation  may  correspond 
more  or  less  closely  in  structure  with  the  normal  tissues.  An  increase  in  the 
amount  of  the  tissue  as  the  result  of  proliferation  is  termed  hyperplasia. 
The  increases  in  the  size  of  the  tonsils  under  conditions  frequently  met  with 
in  early  life  are  examples  of  such  hyperplasia.  Certain  hyperplasias  are 
attributable  to  known  causes  such  as  microorganisms  or  higher  parasites, 
others  are  of  unknown  etiology,  and  we  also  have  examples  of  the  compensa- 
tory hyperplasia  to  supply  an  increase  in  function  by  reason  of  loss  of  parts  or 
other  failure  elsewhere. 

During  hyperplasia  there  is  frequently  a  loss  of  differentiation  of  tissues 
which  von  Hansemann  has  termed  "anaplasia."  In  fact,  it  appears  that 
structural  diflferentiation  may  bear  an  inverse  relation  to  the  rapidity  of  tissue 
growth. 

Metaplasia. — Under  certain  stimuli  certain  tissues  may  not  only  depart 
markedly  from  the  normal  but  become  transformed  to  quite  another  type  and 
this  is  known  as  metaplasia.     The  transformation  of  the  glandular  endome- 


384 


OCCUPATIONAL    AFFECTIONS    OF    THE    SKIN 


trium  into  stratified  squamous  epithelium  as  the  result  of  eversion  of  the 
uterus  has  been  considered  an  example  of  such  metaplasia,  but  here  there  is 
the  possibility  that  the  transformation  is  due  to  replacement  with  squamous 
epithelium  growing  in  from  contiguous  surfaces  rather  than  true  metaplasia. 
A  better  example  is  to  be  found  in  the  transformation  of  the  epithelium  of  the 
bile  ducts  as  the  result  of  the  presence  of  parasitic  worms.  This  organ  is 
completely  isolated  from  all  surfaces  covered  with  squamous  epithelium  and 
may  therefore  be  taken  as  a  true  example  of  metaplasia.     In  certain  forms  of 


Fig.  17. — Hyperplasia  in  vegetable  tissues  due  to  infection  with  a  myxmycete,  Plas- 
modiophora  hrassiccn.  Several  of  the  slendor  normal  roots  of  the  cabbage  are  apparent 
but  nearly  all  are  greatly  thickened  as  the  result  of  proliferation. 

chronic  pancreatitis,  the  glandular  portion  of  the  organ  may  become  greatly 
modified  and  resemble  cancer.  The  bronchial  epithelium  may  also  become 
changed  from  a  columnar  to  a  squamous  type  in  certain  instances.  ^^  Such 
conditions  occur  naturally  but  some  may  also  be  produced  experimentally  by 
infecting  animals  with  the  proper  parasites.  These  changes,  however,  are 
not  to  be  regarded  as  constituting  true  tumor  growth  although  they  may 
closely  simulate  the  latter.  They  dififer  in  this  respect  that  they  are  self- 
limited  and  have  a  tendency  to  return  to  the  normal  especially  when  the 
exciting  cause  is  removed. 


CANCER   AND    OCCUPATION 


385 


Fig.  18. — -Metaplasia  of  the  epithelium  of  the  biliary  ducts  in  fiber  zibethecus  as  the 
result  of  the  presence  of  a  species  of  trematode,  one  of  which  is  shown  in  longitudinal 
section. 


Fig.  19. — Irregular  proliferation  simulating  adeno-carcinoma  in  chronic 
pancreatitis  of  the  cat. 


25 


386  OCCUPATIONAL   AFFECTIONS    OF    THE    SKIN 

Injuries  and  Chronic  Inflammation  as  a  Basis  for  Cancer 

There  is  now  available  a  large  amount  of  data  which  shows  "that  long- 
continued  inflammation  due  to  various  causes  is  frequently  followed  by,  in 
fact  paves  the  way  for,  the  development  of  cancer.  Probably  the  most 
convincing  example  is  the  production  of  cancer  following  long  or  repeated 
exposure  to  the  X-ray,  an  unusual  and  artificial  agent  which  will  be 
referred  to  later  on  in  more  detail.     A  considerable  number  of  tumor  cases 


Fig.  20. — Coccidium  nodule  of  the  rabbit's  liver  simulating  papillary  adenocystoma. 
This  lesion  differs  from  a  tumor  in  that  it  is  self  limited  and,  following  the  elimination 
of  the  causal  agent,  becomes  replaced  by  scar  tissue. 

give  a  history  of  trauma  preceding  the  appearance  of  tumor.  In  this  con- 
nection it  is  necessary  to  take  into  account  the  tendency  of  human  nature 
to  find  a  plausible  cause  to  which  to  attribute  any  infirmity.  We  should 
also  consider  the  undue  prominence  given  certain  injuries  on  account  of 
the  previous  involvement  of  certain  structures  by  tumor.  Thus  an 
individual  attributes  the  development  of  sarcoma  of  a  given  bone  to  a 
blow  or  other  injury  although  it  may  very  well  be  that  no  great  impor- 
tance would  have  been  attached  to  such  an  injury  in  case  the  bone  had 


CANCER   AND   OCCUPATION  387 

been  normal  at  the  time.  From  a  medico-legal  aspect  such  cases  present 
most  perplexing  problems.  It  is  possible,  even  probable,  that  in  a  limited 
number  of  cases,  trauma  is  to  be  considered  as  a  contributory  cause.  The 
principle  cause  would  appear  to  lie  in  the  peculiarity  of  the  individual,  for 
trauma  is  of  so  great  frequency  that  it  cannot  in  any  sense  be  regarded  as 
the  specific  cause  of  any  type  of  tumor.  The  involvement  of  any  portion  of 
the  body  by  the  metastatic  growth  of  tumor  previous  to  a  given  injury  is 
usually  more  easily  determinable  either  by  the  clinical  evidence  of  tumor 
elsewhere,  by  the  histological  character  of  the  tumor,  or  by  post-mortem 
demonstration  of  the  primary  tumor  located  elsewhere.  The  frequency  of 
the  fracture  of  bones  secondarily  invaded  by  tumor  which  has  originated  else- 
where is  familiar.  A  radiograph  taken  as  soon  as  possible  after  the  fracture 
should  usually  show  and  serve  as  a  record  of  the  presence  of  either  primary 
or  metastatic  growth. 

The  number  of  agents  that  are  known  to  produce  chronic  inflammation  of 
such  character  that  new  growth  frequently  follows,  is  continually  growing  and 
it  is  with  certain  of  these  that  we  are  concerned  in  the  consideration  of 
occupational  disease.  There  are  agents  to  which  all  individuals  are  exposed 
to  a  greater  or  less  degree  that  are  mildly  injurious.  The  undue  or  prolonged 
exposure  to  the  skin  to  such  agents  evidently  has  a  tendency  to  bring  on  a 
premature  senility  of  its  tissues  especially  in  certain  individuals.  The  effects 
of  light,  heat,  and  drying  on  the  exposed  portion  of  the  skin  are  familiar  to 
medical  men  and  it  is  upon  these  surfaces,  especially  on  the  face  and  hands, 
that  such  changes  appear  in  later  life.  The  more  immediate  effects  of  undue 
heat  and  cold  on  the  skin  are  well  known,  especially  to  dermatologists,  and 
the  future  condition  of  the  tissues  wiU  depend  on  the  powers  of  repair  in  each 
individual  case.  For  example,  by  the  habitual  application  of  cold,  a  dry 
scaly  condition  of  the  skin  may  be  produced  at  will  in  many  individuals. 
Thus  abnormalities  in  the  form  of  undue  greasiness  and  accumulations  of  the 
cornified  epithelium,  the  so-called  keratosis  senilis,  are  found  on  the  exposed 
portions  of  the  skin  of  the  aged  in  addition  to  a  more  generalized  tendency 
to  atrophy  and  loss  of  hair  and  glands.  Certain  individuals  possess  a  pro- 
nounced idiosyncrasy  to  light,  for  example,  and  light  has  been  shown  to  be 
unusually  injurious  to  individuals  subject  to  a  skin  affection  known  as  Xero- 
derma pigmentosum.^*' 

There  are  certain  specific  diseases  that  produce  chronic  inflammation 
which  is  not  infrequently  followed  by  cancer.  Thus  the  long-continued 
injury  to  the  skin  in  Lupus  vulgaris  serves  as  a  basis  for  the  subsequent 
development  of  cancer.  Cancer  may  also  develop  in  chronic  syphilitic  lesions, 
and  that  there  is  no  incompatibility  for  the  coexistence  of  these  various  dis- 
eases is  shown  by  the  occurrence  of  all  three  in  a  single  patient.^^  In  order 
to  ascribe  etiological  significance  to  these  conditions,  it  should  be  shown  statis- 
tically that  skin  cancer  is  more  frequent  in  such  cases  than  in  an  equal  number 
of  the  population  at  large  of  comparable  age.     The  infection  of  the  pelvic 


388  OCCUPATIONAL  AFFECTIONS  OF  THE  SKIN 

veins  with  a  parasitic  worm,  Schistosomum  hematobium  (Bilharzia),  and 
the  inflammation  resulting  from  the  passage  of  the  ova  of  these  worms 
through  the  bladder  wall  is  said  to  be  frequently  followed  by  carcinoma  of 
the  bladder.  Since  this  infection  is  confined  to  certain  regions  of  the  world, 
in  order  to  prove  this  point  it  should  likewise  be  shown  that  cancer  of  the 
bladder  is  more  frequent  in  such  regions  than  elsewhere.  As  a  matter  of 
fact,  statistics  are  so  fragmentary  and  statements  so  conflicting  with  regard 
to  this  point  that  it  is  impossible  to  draw  any  conclusions.  It  seems  probable 
that  an  undue  amount  of  granulation  tissue  and  hyperplasia  of  the  mucosa 
of  the  bladder  has  given  rise  to  this  view  and  that  with  the  removal  of  the 
cause  such  conditions  would  be  ameliorated  instead  of  progressing  to  a 
fatal  issue  as  is  almost  invariably  the  case  with  true  carcinoma.  Cancer  is 
occasionally  reported  accompanying  infection  with  unusual  parasites.  For 
example,  carcinoma  of  the  bile  passages  or  hver  has  been  noted  in  infection 
of  human  beings  with  a  species  of  fluke  which  is  ordinarily  found  in  the  cat.^^ 

Habits.— Oi  special  interest  is  the  influence  of  habit  on  the  frequency ' 
of  tumors.  The  use  of  alcohol  in  large  amounts  since  it  is  commonly  attended 
with  more  or  less  exposure  or  disease,  is  probably  of  some  importance  in 
bringing  on  a  premature  senility  of  the  tissues.  Likewise  the  tobacco  habit 
may  be  attended  with  long-continued  injury  to  portions  of  the  mucous  mem- 
brane. Countries  in  which  preparations  of  betal  nut  and  lime  are  habitually 
used  for  chewing  purposes  show  a  high  incidence  of  cheek  carcinoma.  ^^ 
Statistics  for  such  countries  are  especially  interesting  in  that  they  show  a 
high  frequency  of  carcinoma  of  the  cheek  in  women,  whereas  new  growth 
in  this  location  is  infrequent  in  women  of  European  nations.  Cancer  of 
the  abdominal  wall  is  relatively  infrequent  in  most  countries,  but  is  fre- 
quent in  this  location  in  certain  parts  of  India  where  the  body  is  warmed 
artificially  by  a  small  stove,  the  Kangri.-* 

Summary. — The  effects  of  the  various  agents  enumerated  should  be  re- 
garded in  various  occupations.  Those  which  involve  excessive  exposure  to 
light,  heat,  and  cold  may  be  expected  to  be  of  influence  in  bringing  on  a  pre- 
mature aging  of  the  exposed  portions  of  the  skin  and  thus  to  factor  in  the 
development  of  skin  cancer.  Since,  however,  most  of  the  tumors  of  this 
type  are  of  comparatively  slight  malignancy,  such  influences  are  not  of  first 
importance.  Occupations  such  as  that  of  the  soldier  which  expose  individ- 
uals to  certain  parasitic  infections,  such  as  Schistosomiasis,  etc.,  must  be 
taken  into  account.  The  occupation  of  the  physician  and  that  of  the  nurse, 
however,  are  not  shown  to  be  dangerous  with  respect  to  direct  infection 
from  cancer  cases.  No  very  marked  preponderance  of  cancer  in  any  of  the 
more  usual  occupations  is  shown  by  Newsholme's  statistics."  The  incidence 
of  cancer  in  chimney  sweeps,  however,  is  more  than  double  than  in  any  of 
the  other  occupations.  Since  these  statistics  are  based  upon  data  relating 
to  cancer  in  general,  it  is  not  remarkable  that  they  show  no  more.  If  the 
statistics  were  collected  for  each  type  of  tumor  much  more  significant  results 


CANXER    AND    OCCUPATION  389 

would  be  expected  with  reference  to  the  occupation.  Notwithstanding 
this  there  is  a  strikingly  high  incidence  in  chimney  sweeps. 

Special  Occupations.— The  distribution  and  character  of  the  tumors 
and  the  preceding  conditions  which  are  associated  with  certain  occupations 
are  of  special  interest.  The  occupations  which  have  to  do  with  the  manu- 
facture or  use  of  certain  coal-tar  products  are  to  be  especially  considered. 
In  such  occupations  the  exposure  of  skin  surfaces  to  the  irritating  substances 
is  said  to  be  followed  by  a  more  or  less  characteristic  type  of  inflammation 
or  by  warty  growths.  The  Uability  to  tumors  under  such  circumstances  is 
recognized  in  England  so  that  certain  trades  are  scheduled  as  coming  under 
the  workmen's  compensation  act.  It  is  said,  however,  that  addiction  to 
alcohol  tends  to  diminish  such  personal  hygiene  as  would  readily  prevent 
the  prolonged  action  of  the  materials  used.  Workers  with  aniline  oil  fre- 
quently develop  carcinoma  of  the  bladder  and  it  is  believed  that  this  substance 
in  the  process  of  excretion  remains  for  a  time  in  the  bladder  and  so  excites 
the  proliferation  which  follows.-^  Certain  individuals  also  show  a  pecuUarly 
marked  reaction  to  arsenic  so  that  those  trades  in  which  arsenical  compounds 
are  used  would  prove  dangerous  in  such  instances.  Osier  states  that  Cobalt 
miners  are  said  to  be  prone  to  primary  carcinoma  of  the  lung,  an  organ  which 
is  ordinarily  rarely  the  primary  site  of  cancer. 

Medico-legal  Aspect. — The  medico-legal  aspect  of  the  subject  is  of  some 
importance.  Usually  no  more  than  a  contributory  influence  is  to  be  claimed 
with  respect  to  injury  in  the  causation  of  new  growth.  In  a  limited  number 
of  trades  and  occupations,  however,  the  careless  use  of  materials  such  as  cer- 
tain coal-tar  products  or  physical  forces  such  as  the  X-ray  and  radium  should 
always  be  emphasized  and  measures  taken  to  avoid  all  unnecessary  exposure. 
The  dangers  in  the  use  of  X-ray  are  at  the  present  time  so  well  understood 
that  it  would  appear  that  the  majority  of  injuries  produced  should  be  con- 
sidered as  due  to  ignorance  or  carelessness,  whether  the  injury  effects  operator 
or  patient.  There  are  as  yet  no  recorded  cases  of  carcinoma  arising  from 
radium  burns  but  the  similarity  of  the  more  penetrating  rays  of  radium  and 
of  its  biological  effects  leads  to  the  expectation  of  similar  results  and  to  a 
warning  against  the  indiscriminate  or  careless  use  of  this  agent. 

This  book  was  received  while  revising  the  page  proof  of  this  Chapter. 
Dr.  Hoffman"  devotes  28  pages  to  the  mortality  from  cancer  in  different 
occupations  and  presents  an  excellent  review  of  the  literature  of  the  subject 
with  special  reference  to  cancer  among  chimney  sweeps,  gardners,  petroleum 
industry  and  paraffin  workers,  coal,  soot,  tar  and  pitch  workers,  includ- 
ing the  patent  fuel  industry,  brewers,  furriers,  skinners,  seamen,  tinplate 
workers,  lead  workers,  rubber  workers,  chemical  workers  and  X-ray  workers. 
The  relation  of  cancer  to  injuries  is  emphasized  by  quotations  from  Greer's 
treatise  on  Industrial  Diseases  and  accidents. 

A  very  valuable  reference  on  the  effect  of  the  synthetic  dye  industry  on 
the  occurrence  of  tumors  by  Dr.  S.  G.  Leuenberger  of  Zurich  will  be  found 
on  page  68.     Another  valuable  contribution  is  referred  to  on  pages  61  and  68. 


390  OCCUPATIONAL  AFFECTIONS  OF  THE  SKIN 

It  deals  with  the  remarkable  prevalence  of  malignant  disease  of  the  lungs  in 
the  miners  in  the  Schneeberg  district  in  Saxony.  The  minerals  mined  being 
mostly  nickel,  cobalt  and  bismuth.  Harting  and  Hesse  in  1878  reported  that 
a  lymphosarcoma  of  the  bronchial  lymph  nodes,  or  an  endothelial  sarcoma 
was  responsible  for  75  per  cent,  of  all  the  deaths  among  the  miners.  Arnstein 
in  a  recent  investigation  found  that  between  1907-1911  all  the  miners  ad- 
mitted to  the  hospital,  entered  with  a  diagnosis  of  cancer  of  the  lung  and  it 
was  given  as  the  cause  of  death  in  44  per  cent,  of  the  death  certificates.  In 
the  opinion  of  Arnstein  it  is  probable  that  in  many  cases  tuberculosis  and 
possibly  also  pneumoconiosis  may  have  been  erroneously  diagnosed  as  cancer 
of  the  lung  as  necropsies  are  rare.  In  the  two  cases  which  he  was  able  to 
examine  post-mortem,  the  trouble  proved  to  be  chronic  pulmonary  tubercu- 
losis in  one  case  but  in  the  other  true  carcinoma  of  the  lung  with  metastasis. 
He  urges  further  study.     See  also  J.  A.  M.  A.,  June  28,  1913. 

The  English  mortality  statistics  referred  to  on  page  71,  bring  out  the  fact 
that  "the  highest  standardized  cancer  death  rate  occurred  among  chimney 
sweeps  for  which  occupation  the  rate  was  224.9  P^^*  100,000  exposed  to  risk. 
The  rate  for  seamen  was  170.5  and  for  brewers  166.6.  Relatively  high,  but 
not  abnormally  excessive,  cancer  death  rates  are  met  with  in  the  following 
occupations:  Fishermen  111.9;  tailors  112. 9;  textile  workers  112. 6;  lawyers 
III. 8;  innkeepers  108.8;  corn-millers  105.3;  gas  works  service  107. i;  shoe- 
makers 103.2;  and  butchers  102.8.  Lower  cancer  death  rates  but  still  sug- 
gestive of  special  predisposing  conditions  are  met  with  in  the  following  occu- 
pations: Farmers  and  graziers  94.8;  farm  laborers  79.7 ;  gardners  and  nursery- 
men 85.2." 

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"  Farmer,  Moore  and  Walker. — Proc.  Roy.  Soc,  1903,  72. 

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"  Haythorne. — Journal  of  Medical  Research,  1912,  XXVI,  523. 
^^  Councilman  and  Magrath. — Journal  of  Medical  Research,  XXI,  331. 

21  Kellert. — Journal  American  Medical  Association,  Vol.  LXIII,  No.  21,  Nov.  21,  1914. 

22  Braun. — Animal  Parasites  of  Man.     William  Wood  &  Co.,  1908,  165. 

"  Davis. — Jour.  Amer.  Med.  Assoc,  Vol.  LXIV,  No.  9,  Feb.  27,  1915,  page  711. 

2"'  Bashford. — Third  Scientific  Report  of  the  Imperial  Cancer  Research  Fund,  1908. 

"  Newsholme. — The  Practitioner,  1899,  LXII,  371. 

^'^  Davis. — Jour.  Amer.  Med.  Assoc,  May  30,  1914,  page  1716. 

2^  Hoffman,  F.  L. — The  Mortality  from  Cancer  throughout  the  World,  Prudential  Press,  1915. 


2.  X-RAY.  RADIUM 
X-ray- 
Exposure  to  the  Rontgen  rays,  more  particularly  the  repeated  exposure 
of  X-ray  operators  without  adequate  protection,  over  a  long  period  of  time, 
has  produced  skin  lesions  which  have  in  numerous  instances  eventually 
been  followed  by  true  cancer.  Thus  the  causal  relation  of  the  X-ray  and 
cancer  is  now  a  well-known  and  an  established  fact. 

It  has  long  been  known  that  characteristic  burns  might  be  produced  by 
exposure  to  the  X-ray.  These  burns  differ  in  many  respects  from  those 
caused  by  heat;  there  may  be  a  considerable  latent  period  between  the  ex- 
posure and  the  subsequent  appearance  of  the  inflammatory  reaction.  This 
interval  may  vary  from  a  few  hours  to  several  days  or  even  weeks;  the  burn 
is  of  longer  duration,  the  heahng  may  be  very  slow,  requiring  weeks  and  even 
many  months;  in  some  instances  healing  does  not  occur,  and  there  may  be  a 
persistent  chronic  ulcer  which  may  become  cancerous,  particularly  during 
scar  formation. 

The  degree  of  the  acute  reaction  following  exposure  to  the  X-rays  is  very 
variable,  depending  on  several  factors,  namely:  the  intensity  and  quality 
of  the  radiation,  the  duration  of  the  exposure,  the  part  of  the  body  exposed, 
and  the  individual  sensitiveness  or  tolerance.  The  intensity  and  quality 
of  the  rays  depend  upon  the  amperage,  voltage,  the  distance  from  the  tube 
and  the  filtration  and  protection.  Gocht^  claims  there  is  no  special  idio- 
syncrasy to  the  X-ray  as  was  at  one  time  believed.  The  effects  depend  on 
the  quantity  of  rays  absorbed  by  the  tissue. 

Acute  X-ray  Dermatitis. — Depending  on  the  factors  above  referred  to, 
acute  X-ray  dermatitis  may  appear  as  a  slight  or  intense  erythema  varying 
in  shade  from  a  light  pink  color,  which  is  more  or  less  transitory,  and  may  have 
a  shghtly  punctate  character,  to  a  deep  red  erythema,  which  may  not  disap- 
pear even  on  pressure.  This  is  often  accompanied  by  itching.  The  ery- 
thema, if  intense,  may  fade  slowly  and  be  followed  by  brownish  pigmentation. 
On  the  other  hand  vesiculation  may  result,  with  subsequent  exfoHation  of 
the  surface  layers.  Ulceration  in  varying  degree  and  even  sloughing  may 
occur.  The  acute  reactions  most  frequently  occur  in  patients  exposed  to 
the  X-ray  for  diagnosis  or  treatment;  such  injuries  have  caused  much  suf- 
fering and  disability,  and  many  legal  suits,  often  most  disastrous  to  physicians, 
have  resulted. 2 

The  mucous  and  serous  surfaces  seem  to  be  more  resistant  to  injury  by 
the  X-ray  than  the  skin,  while  the  appendages  of  the  skin  are  even  more 

391 


392  OCCUPATIONAL  AFFECTIONS  OF  THE  SKIN 

easily  afifected.  Marked  changes  in  the  hair  folHcles  often  lead  to  falling 
out  of  the  hair;  dryness  of  the  skin  due  to  injury  of  the  sweat  glands  is 
common. 

Normal  living  tissues  are  said  to  be  afifected  in  the  following  order: 
lymphoid  tissue,  epithelial  cells  of  the  glands,  the  hair  follicles,  skin,  lining 
of  the  blood-vessels,  and  to  a  much  less  extent  the  cells  and  fibers  of  muscles 
and  connective  tissue. 

From  the  standpoint  of  occupational  disease,  however,  the  chronic  changes 
caused  by  repeated  exposure  to  relatively  small  doses  of  X-ray  over  a  long 
period  of  time  are  of  far  more  importance  than  the  acute  reactions  above 
referred  to.     They  may  be  discussed  as  to  the  local  and  general  eflfects. 

Chronic  X-ray  Dermatitis  and  Cancer. — Chronic  X-ray  dermatitis  is  the 
term  given  to  the  changes  produced  in  the  skin  by  repeated  exposure  to 


Fig.  21. — Photograph  of  the  left  hand  and  wrist  of  a  Rontgenologist  who  had  been 
engaged  in  X-ray  work  for  ten  years  (Huntington  Hospital  No.  C.  O.  14,  240). 

The  lesions  chiefly  on  the  palmar  surface,  which  is  unusual,  consist  of  scaling,  fissures, 
keratoses,  atrophy,  telangiectases  and  pigmentation. 

relatively  small  doses  of  X-ray.  In  certain  instances  they  may  be  preceded 
by  acute  reactions;  the  characteristic  changes  are  closely  analogous  to  those 
found  in  the  skin  of  the  aged,  or  of  those  exposed  to  the  elements.  Similar 
changes  may  be  produced  in  the  skin  of  the  paraffine  worker  and  the  chimney 
sweep.  The  atrophy,  keratosis  and  localized  scaling  is  so  like  that  of  age, 
that  the  chronic  effects  of  the  X-ray  upon  the  skin  have  been  claimed  by 
some^  to  be  prematurely  induced  senescence. 

In  addition  to  the  atrophy,  scaling  and  keratosis,  there  is  also  pigmen- 
tation, development  of  fissures  and  telangiectasis,  which  may  be  marked 
(Fig.  21);  loss  of  hair  and  dryness  of  the  skin  are  frequent;  then  ails  may  be- 
come brittle,  ribbed  and  chipped  (Fig.  23).  Beneath  the  keratoses  changes 
occur  in  the  underlying  blood-vessels  and  connective  tissue,  the  epidermis 
may  invade  the  corium  and  true  carcinoma  may  result,  with  metastasis, 


X-RAY.      RADIUM 


393 


not  only  in  the  regional  glands,  but  even  widely  disseminated.     This  repre- 
sents the  first  real  experimental  cancer.'* 

Cancer  may  develop  not  only  in  preexisting  papillomata  and  keratoses, 
but  also  in  the  intractable  chronic  ulcers  caused  by  the  X-ray,  either  by 
intense  single  or  repeated  exposures.  Many  cases  are  reported  of  the 
development  of  cancer  in  patients  who  have  undergone  X-ray  treatment  for 


Fig.  2  2. — Photograph  of  an  X-ray  demonstrator  showing  on  the  chest  keratoses,  telan- 
giectases and  pigmentation;  on  the  hands  keratoses,  fissures  and  loss  of  left  fore-finger 
due  to  previous  amputation  for  X-ray  carcinoma.  In  the  left  axillary  region  a  black  line 
indicates  the  anterior  border  of  a  metastatic  cancer  mass.  These  chest  lesions  were 
caused  by  repeatedly  demonstrating  the  heart  outline  and  action  by  fluoroscope  and  the 
lesions  on  the  left  hand  were  due  to  the  use  of  the  latter  for  a  penetrometer  and  as  an 
object  of  demonstration  for  bone  structure.  Man  first  began  X-ray  work  in  1897.  The 
case  was  previously  reported  by  Porter,  No.  VII.  of  his  1909  series,  also  Huntington  Hos- 
pital, No.  C.  O.  15.  I.  Jan.,  1915. 


lupus;  indeed,  this  disease  may  in  certain  instances  be  followed  by  cancer, 
even  without  treatment  by  the  X-ray.  Mendes  da  Costa^  cites  71  cases  of 
lupus  in  which  the  X-ray  was  used;  of  these  seven  became  cancerous.  Schur- 
mann^  thinks  the  danger  of  cancer  from  X-ray  treatment  of  lupus  is  shght 
when  compared  with  its  extensive  use  and  the  fact  that  cancer  may  occur  in 
lupus  without  the  use  of  the  X-ray. 

The  pioneer  workers  with  the  X-ray  little  suspected  the  dangers  of  occu- 


394 


OCCUPATIONAL  AFFECTIONS  OF  THE  SKIN 


pational  disease  and  the  late  occurrence  of  serious  injury  among  them  is 
appalling  (Figs.  22,  23,  24).  Many  cases  have  now  been  reported  which 
emphasize  the  importance  of  adequate  protection  and  care  in  working  with 
the  X-ray.  Porter'^  in  a  most  admirable  article  has  reported  a  considerable 
number  of  cases,  and  discussed  methods  of  treatment.  Of  the  symptoms 
caused  by  X-ray  injuries  pain  is  most  distressing;  in  certain  instances  it  is 
agonizing;  disability  may  be  great. 

Goeneu^  found  a  mortahty  of  24  per  cent,  in  33  cases  of  X-ray  carcinomata 
gathered  from  the  literature,  while  of  ten  cases  reported  by  Porter  and  White^ 


Fig.  23. — Photograph  showing  details  of  Fig.  22,  i.e.,  telangiectases,  keratoses  and 
pigmentation  of  chest,  the  bulbous  stump  of  the  left  fore-finger,  the  multiple  keratoses, 
crusts,  and  fissures,  and  the  chipping  and  ribbing  of  the  nails  on  the  left  hand,  which  is 
laid  across  the  chest. 


six  died  in  spite  of  surgical  operation.  Various  other  writers  have  reported 
single  or  a  series  of  cases  of  X-ray  carcinoma.^" 

It  is  important  to  note  that  these  X-ray  carcinomata  are  frequently 
multiple,  ^"^  there  are  usually  several  centers  of  growth.  ^^ 

Sarcoma^^  as  well  as  carcinoma  may  result  from  exposure  to  the  X-rays. 

Of  the  36  cases  of  X-ray  carcinomata  collected  by  Porter,^  34  were  in 
professional  X-ray  workers  (Figs.  22,  23,  24),  and  two  in  patients,  the  latter 
with  abdominal  tumors  which  had  been  treated  for  a  long  time. 


X-RAY.       RADIUM 


395 


Histology  of  Chronic  X-ray  Dermatitis  and  Carcinoma. — Wyss,*  Unna,^ 
and  Wolbach,^^  agree  that  the  epithehum  is  not  primarily  affected  but  that 
the  essential  changes  are  in  the  underlying  connective  tissue  and  blood- 
vessels. There  is  sufficient  injury  so  that  complete  repair  does  not  take 
place — degenerative  and  reparative  process  go  on  in  the  corium  but  the  vas- 
cular lesions  are  progressive.  Young  fibroblasts  were  described  by  Wolbach 
in  the  media  of  the  small  blood-vessels  which,  from  the  proliferation  of  the 
connective  tissue  and  the  swelling  of  the  collagenous  material,  may  be  in 
certain  instances  obliterated. 


Fig.  24. — Photograph  showing  ulcerations  on  chest  of  a  demonstrator  of  X-ray  apara- 
tus  due  to  the  removal  of  numerous  X-ray  keratoses  by  actual  cautery;  between  these 
pigmentation  and  telangiectases  are  seen.  The  stump  of  the  fore-finger  the  site  of  a  pre- 
vious X-ray  cancer,  and  the  middle  finger  have  been  amputated  because  of  recurrence; 
the  scar  in  the  left  axilla  indicates  where  a  large,  metastatic  cancer  mass  was  removed; 
the  primary  growth  was  on  the  left  fore-finger.     Feb.  8,  1915. 


The  necrotic  foci  found  in  both  the  superficial  and  deep  corium  are 
probably  of  vascular  origin.  The  cells  in  the  basal  layers  of  the  epithehum 
may  show  many  mitoses.  Only  by  the  downgrowth  of  the  epithelium  is 
it  able  to  reach  viable  connective  tissue.  The  glands  are  atrophied  and  the 
fat  tissue  is  absorbed  and  replaced  by  connective  tissue. 

Hyperkeratosis,  rarification  of  the  corium,  irregularity  of  the  papillae  are 
common;  cell  infiltration,  especially  lymphoid  and  plasma,  is  variable. 
Epithelium  may  be  found  growing  into  necrotic  foci  and  into  thrombosed 


396  OCCUPATIONAL   AFFECTIONS    OF    THE    SKIN 

telangiectases;  in  more  advanced  cases  epithelial  pearls  situated  in  the 
deeper  structures  are  frequent,  giving  an  appearance  differing  in  no  way, 
histologically,  from  a  true  epidermoid  carcinoma. 

General  Effects  of  the  X-ray. — Much  less  is  known  of  the  deeper  and  more 
general  chronic  effects  due  to  exposure  to  the  X-ray.  It  has,  however,  been 
definitely  established  that  the  sexual  glands  are  particularly  affected.  Atro- 
phy of  the  ovaries  and  testicles  may  occur  with  resulting  sterility;  changes 
take  place  also  in  the  blood,  lymphatic  tissue  and  bone  marrow.  An£emia, 
even  of  the  pernicious  type,  may  be  produced  and  blood  findings,  similar  to 
those  described  from  exposure  to  radium,  are  frequent,  particularly  in  the 
form  of  a  relative  lymphocytosis.^^  On  the  other  hand,  it  has  been  claimed 
that  certain  cases  of  leukemia  have  resulted  from  exposure  to  X-ray. 

In  a  series  of  mice  and  rats  exposed  repeatedly  to  the  X-rays,  marked 
changes  were  found  in  the  lymphatic  tissue;  the  spleen  was  markedly  affected 
being  very  much  reduced  in  size  due  to  destruction  of  the  Malpighian  cor- 
puscles and  other  cellular  elements. '^'*  In  such  animals  resistance  to  infection 
is  markedly  decreased. ^^  Certain  cases  of  myelogenous  leukemia,  after  ex- 
posure of  the  spleen  to  the  X-ray,  if  special  precaution  is  taken  regarding 
screening,  protection  and  dosage  show  a  marked  reduction  in  the  size  of 
the  greatly  enlarged  spleen,  great  decrease  in  the  white-cell  count,  and  more 
or  less  temporary  improvement  in  the  general  condition  of  the  patient. 
Leucocytolytic  substances  are  said  to  have  been  found  in  the  blood  of  such 
cases. 

Toxaemia  of  varying  degree  may  be  produced  by  exposure  to  the  Rontgen 
ray,  particularly  in  patients  in  whom  there  is  poor  elimination  by  the  kidneys. 
Slight  toxaemias  have  been  noted  by  EdsalP^  even  after  diagnostic  exposures 
in  such  patients.  Profound,  even  fatal,  toxaemias  have  been  recorded;  such 
a  severe  case  with  resulting  stupor  has  been  personally  observed  by  us. 

This  toxaemia  may  be  the  result  of  poisoning  from  failure  to  "eliminate 
products  of  protein  metabolism.  There  may  be  increase  of  total  nitrogen, 
ammonia,  urea  in  the  urine,  and  nitrogen  retention  in  the  blood.  On  purin 
free  diet  there  is  to  be  found  an  increase  in  endogenous  protein  metabolism. 

Other  general  effects  of  the  X-ray  are  said  to  occur;  lassitude  is  of  common 
occurrence,  frequently  patients  doze  or  even  fall  asleep  while  undergoing 
X-ray  treatment  and  there  is  often  a  feeling  of  undue  fatigue  after  long  ex- 
posure.    Alopecia  is  common  in  X-ray  operators  and  patients  exposed. 

The  details  of  the  pathological  findings  have  been  described  by  Cavazzeni 
and  Minelli^''  in  a  post-mortem  examination  of  one  who  had  been  exposed 
to  the  X-ray  for  many  years. 

Treatment. — The  best  treatment  for  acute  Rontgen  dermatitis  is  said  by 
Dodd^^  to  be  the  liberal  application  of  whitewash  which  is  sopped  on  the 
inflamed  area  but  not  to  be  used  with  a  dressing.  He  decries  the  use  of 
ointments.     The  formula  given  by  Dodd  is  as  follows: 


I 


X-RAY.      RADIUM  397 

% 

I^.      Zinc  oxide 30    5i 

Phenol 2     3ss 

Glycerine .' 4     5i 

Limewater 240     5  viii 

Sig. — Shake  well  and  bathe  area  for  5  to  10  minutes,  twice  or  three  times 
a  day. 


For  slight  burns  Unna's  zinc  gelatine,  and  for  the  more  chronic  conditions 
on  the  hands  compound  tincture  of  benzoin,  may  be  used. 

The  chronic  changes  produced  in  the  skin  by  the  X-ray  require  varied 
treatment  depending  on  their  nature.  The  so-called  precancerous  keratoses, 
papillomata  and  ulcers,  call  for  excision,  curettage,  or  skin-grafting,  and  the 
more  border-line  and  cancerous  lesions  may  demand  amputation.  Porter^ 
in  the  excellent  article  above  referred  to  describes  the  treatment  of  these 
lesions  in  detail.  Recently  Caldwell^^  has  called  attention  to  the  value  of 
surface  applications  of  radium  in  the  less  severe  and  strictly  cutaneous 
chronic  lesions,  such  as  fissures,  persistent  scaling  and  keratoses.  Freezing 
methods  and  the  electric  spark,  are  more  painful. 

Of  even  greater  importance  than  treatment  in  individual  cases  is  the  mat- 
ter of  preventing  these  injurious  effects  of  the  X-ray. 

Prophylaxis. — As  our  knowledge  of  these  injurious  effects  has  increased, 
many  methods  have  been  devised  to  prevent  exposing  the  body  of 
the  operator  to  the  rays,  and  of  adequately  protecting  the  patient. 
For  the  X-ray  worker  mirrors,  cords  and  pulleys  have  been  planned  for 
indirect  observation  of  the  patients  and  control  of  apparatus.  Protection 
for  the  operator  in  the  form  of  leaded  cabinets,  screens,  gloves,  aprons,  etc., 
have  been  provided.  These  are  well  illustrated  in  special  works  in  Ront- 
genology and  in  catalogues  of  dealers  in  X-ray  apparatus. 

The  patient  is  now  more  carefully  guarded  by  screens,  leaded  cloth  and 
more  particularly  by  our  knowledge  of  dosage,  filtration  and  protection,  each 
varying  with  the  object  of  the  treatment.  Exposures  should  be  as  short  as 
possible  and  other  forms  of  irritation  of  the  skin  avoided.  The  details  of 
the  appropriate  technique  will  be  found  in  the  general  or  special  works  on 
Rontgenology  and  in  its  application  to  the  diagnosis  and  treatment  of  patho- 
logical conditions  of  the  various  special  organs  for  which  such  procedure  is 
of  value. 

That  such  prophylactic  measures  are  adequate  is  probable  from  the 
fact  that  those  who  have  carefully  used  such  measures  though  engaged  in 
X-ray  work  for  over  12  years  have  not  suffered  any  harmful  effect. 

RADIUM 

The  increasing  use  of  large  quantities  of  radium  for  therapeutic  purposes 
makes  it  important  to  describe  in  detail  the  symptoms  and  signs  produced 
by  it  and  to  emphasize  the  importance  of  these  as  occupational  injuries  so 
that  more  serious  late  effects  may  not  result. 


398 


OCCUPATIONAL  AFFECTIONS  OF  THE  SKIN 


Rutherford^"  States  that  "Walkhoff  first  observed  that  radium  rays  pro- 
duce burns  of  much  the  same  character  as  those  caused  by  Rontgen  rays. 
Experiments  in  this  direction  have  been  made  by  Giesel,  Curie  and  Becquerel 
and  others  with  very  similar  results.  There  is  at  first  a  painful  irritation, 
then  inflammation  sets  in,  which  lasts  from  lo  to  20  days.  This  effect  is 
produced  by  all  preparations  of  radium,  and  appears  to  be  due  mainly  to 
the  a  and  /3  rays.  Care  has  to  be  taken  in  handling  radium  on  account  of 
the  painful  inflammation  set  up  by  the  rays.  If  a  finger  is  held  for  some 
minutes  at  the  base  of  a  capsule  containing  a  radium  preparation,  the  skin 
becomes  inflamed  for  about  15  days  and  then  peels  off.  The  painful  feeling 
does  not  disappear  for  2  months." 

Although  these  rather  acute  reactions  due  to  radium  are  apparently  well 
known  to  physicists,  working  with  radioactive  substances,  and  considerable 
experimental  work  has  been  done  on  animals  by  biologists,  very  little  at- 
tention has  been  paid  to  the  more  chronic  changes. 


Fig.  25. — Photograph  of  the  thumb,  index-,  middle-  and  ring-fingers  of  the  left  hand 
showing  the  scaling  of  the  thickened  superficial  layer  of  the  skin  on  the  radial  side  of 
the  terminal  phalanges;  this  is  due  to  the  handling  of  radium  in  making  therapeutic 
applications. 

The  increasing  use  of  large  quantities  of  radium  should  call  attention 
to  these  changes  not  only  because  of  the  annoyance  and  discomfort  caused 
but  as  a  warning  froni  analogy  to  the  X-ray  of  more  serious  late  effects,  such 
as  atrophy,  intractable  ulceration  and  even  cancer.  Already  in  certain 
instances  there  has  been  caused  not  only  great  annoyance  from  discomfort 
but  actual  impairment  in  manual  dexterity  in  performing  delicate  manipula- 
tions because  of  persistent  local  anaesthetic  effects. 

The  symptoms  caused  by  handling  radium  may  occur  very  insidiously 
and  consist  of  blunting  of  sensibility  of  the  finger  tips,  paraesthesia  such  as 
increased  sensitiveness  to  heat  and  pressure,  amounting  at  times  to  actual 
pain,  and  anaesthesia  of  varying  degree. 

The  subjective  disturbances  are  out  of  all  proportion  to  the  objective 
findings  which  include  flattening  of  the  natural  ridges  on  the  effected  fingers 


X-RAY.      RADIUM 


399 


with  consequent  changes  in  the  characteristic  markings  of  the  finger  prints, 
thickening  of  the  horny  layer  of  the  epidermis  with  scaling  in  varying  degree 
(Fig.  25),  failure  of  the  tips  of  the  fingers  to  resume  their  normal  shape  after 
pressure — a  sort  of  pitting,  upgrowth  of  the  cuticle  at  the  base  of  and  under- 
neath the  nails  which  tend  to  stand  off  from  the  fleshy  part  of  the  fingers 
and  which  become  easily  cracked  and  extremely  brittle  (Fig.  26). 

Various  general  symptoms  such  as  headache,  malaise,  weakness,  undue 
fatigue,  unusual  need  of  sleep,  increased  excitability,  fretfulness,  irritability, 
disorders  of  menstruation,  attacks  of  dizziness,  etc.,  have  been  said  by  Gud- 
zent  and  Halberstaedter^^  to  be  caused  by  repeated  and  long-continued  ex- 
posure to  radioactive  substances.     Such  symptoms  are,  however,  common 


Fig.  26. — Photographs  of  fingers  showing  how  the  free  edge  of  the  nails  stands  away 
from  the  fleshy  part  of  the  affected  finger  tips;  the  upgrowth  of  the  horny  skin  beneath 
the  nails  is  marked.  The  changes  are  the  result  of  handling  radium  in  making  thera- 
peutic applications. 


in  many  people  at  times  and  as  they  cannot  be  accurately  and  objectively 
recorded  there  is  doubt  if  they  can  be  definitely  proved  to  be  due  to  exposure 
to  radium.  They  may  be  due  to  close  confinement,  tiring  routine  and  lack 
of  out-door  exercise  and  other  causes.  The  exposures  of  some  of  the  cases 
reported  were  doubtless  large;  some  were  assistants  in  "Fabriks"  for  manu- 
facture of  radium  apparatus  and  some  had  been  engaged  for  years  during  the 
entire  day  in  work  with  radioactive  substances.  It  is  therefore  probable 
that  certain  general  symptoms  do  occur  as  a  result  of  exposure. 

Changes  in  the  blood  of  radium  workers  were  observed  by  Gudzent 
and  Halberstaedter.  Most  striking  was  the  relative  and  absolute  increase  in 
lymphocytes  from  36  per  cent,  to  63  per  cent.,  average  of  10  cases  46.4  per 
cent.;  a  relative  and  absolute  decrease  in  neutrophils,  average  50.3  per  cent. 
There  was  little  change  in  red  blood  corpuscles,  slight  diminution  in  white 
cells  and  the  hemoglobin  was  lowered  in  only  two  cases,  70  per  cent,  and  71 
per  cent,  respectively. 

Various  methods  have  been  devised  for  avoiding  these  injurious  effects 
by  the  least  possible  contact  of  the  fingers  with  the  radium.  Forceps  or 
special  vices  are  used  for  holding  tubes  and  screwing  in  or  out  the  tips  and 
eyes;  special  applicators  in  the  form  of  metal  boxes  have  been  constructed 


400  OCCUPATIONAL  AFFECTIONS  OF  THE  SKIN 

SO  that  the  active  tubes  may  be  added  after  the  filtration  and  protection 
have  been  arranged,  and  the  surface  applicator  is  then  slipped  by  forceps 
into  a  special  rubber  envelope  and  fastened  with  adhesive.  This  is  par- 
ticularly to  avoid  wrapping  the  radium  up  by  hand  in  sheet  rubber.  Leaded 
gloves,  fingers,  etc.,  are  clumsy  and  are  not  readily  worn. 

In  placing  active  tubes  in  special  applicators  it  will  probably  not  be 
possible  to  avoid  all  contact  with  radium  and  as  the  effects  are  not  apparent 
at  once,  as  when  handling  very  hot  objects  such  as  heated  glass,  but  only  after 
a  period  of  days  or  even  weeks,  it  will  be  difficult  to  train  a  worker  to  avoid 
all  contact  with  the  active  apparatus. 

In  the  work  of  making  routine  applications  of  radium  there  should  be  a 
rotation  in  the  staff  and  persons  effected  should  be  freed  at  least  temporarily 
from  such  work. 

In  order  to  avoid  general  disturbances  the  body  should  be  protected  as 
far  as  possible  by  metal  screens  in  form  of  boxes  or  plates  about  the  radium; 
there  should  be  frequent  ventilation  of  workrooms,  particularly  if  there  is 
radium  emanation  present,  and  a  change  of  duty  and  shorter  hours;  periodic 
physical  examination  of  those  working  with  radioactive  substances  with  spe- 
cial reference  to  the  blood  examination  is  indictaed. 

Summary  and  Conclusions. — From  the  above  it  is  evident  that  marked 
changes  may  occur  on  the  fingers  of  those  engaged  in  routine  work  with  radio- 
active substances.  These  local  objective  changes  consist  chiefly  of  flatten- 
ing of  the  characteristic  ridges,  thickening  and  scaling  of  the  superficial  layers 
of  the  skin  and  even  atrophy  and  intractible  ulceration.  These  lesions  are 
usually  slight  compared  with  the  marked  subjective  symptoms,  such  as  par- 
aesthesia,  anaesthesia  of  varying  degree,  tenderness,  throbbing  and  even  pain. 
The  persistence  of  such  effects  is  noteworthy. 

Various  general  systemic  symptoms  and  also  blood  changes  may  be 
produced  by  exposure  to  radioactive  substances.  To  avoid  such  local  and 
general  disturbances  special  protective  and  preventive  measures  have  been 
devised  and  those  engaged  in  routine  handling  of  radioactive  substances  are 
particularly  cautioned. 

REFERENCES 

1  Gocht. — Berl.  Klin.  Woch.,  igog-io. 

2  Gottheil,  W.  S. — X-ray  Uses,  Dangers  and  Abuses.     Jour.  A.  M.  A.,  Nov.  21,  1908. 
»  Unna.— Fortschr.  a.  d.  G.  d.  R.,  Bd.  VIII,  S.  66. 

*  Wyss,  M.  O.— Entsteshung  des  Rontgencarcinomus  der  Haut  und  des  Carcinomus  im 

Allgemeine.  Beitrage  zur  Klinische  Chirurgie,  XL VI,  1906,  S.  1S5. 
^  Mendes  da  Costa. — Revue  pratique  des  maladies  cutan.,  1905,  page  224. 
^  Schumann,  E.— Entstechung  bosartiger  Neubildungen  auf  der  rontgenbestralbilten  Haut. 

Archiv  fiir  Klin.   Chirurgie,   Berlin,  LXXXIV,  No.  3,  1907.     Rep.  VII  collected 

cases  and  one  of  own  esp.     Histology. 
^  Porter,  C.  A. — The  Surgical  Treatment  of  X-ray  Carcinoma  and  Other  Severe  X-ray 

Lesions  Based  upon  an  Analysis  of  Forty-seven  Cases.     Jour,  of  Med.  Research, 

Vol.  XXI,  1909,  page  357. 


X-RAY.       RADIUM  4OI 

8  Coeneu.— Berl.  Klin.  Wochensch.,  1909,  Xo.  7. 

'  Porter,  C.  A.  and  White  C.  J. — ^Multiple  Carcinomata  Following  Chronic  X-ray  Derma- 
titis.    Annals  of  Surgery,  Xov.,  1907. 

'"Lindenborn,  Karl.— Ueber  Rontgentumoren.  Beitrage  zur  Klin.  Chirurgie,  Vol.  LIX, 
190S,  page  384. 

1'  Rosenbach,  Fritz. — Das  Rontgencarcinom  und  seine  entstehung.  Archiv  f.  Klin, 
Chirurgie,  Bd.  XCII,  S.  i,  1910. 

12  Wolbach,  S.  B. — Pathologic  Histology  of  Chronic  X-ray  Dermatitis  and  Earl)-  X-ray 
Carcinoma.     Journal  Med.  Research,  Oct.,  1909. 

^' Von  Jagic,  X.,  Schwarz,  G.,  v.  Siebenrock,  L. — The  Blood  Findings  in  Rontgenologists. 
Berl.  Klin.  Wochenschr.,  July  3,  191 1,  XL VIII. 

"  Heinecke. — Archiv  of  Rontgen  Rays,  1907. 

**  Murphy,  J.  B.,  and  Ellis,  A.  \V.  L. — Jour.  E.xper.  Med.,  Vol.  XX,  Xo.  i,  Oct.  i,  1914, 
page  397. 

'*  Edsall,  D.  L.,  and  Pemberton,  B. — Xature  of  General  Toxic  Reaction  Following  Exposure 
to  Rontgen  Rays.     Amer.  Jour,  of  !Med.  Sc,  Mar.,  1907. 

^"  Cavazzeni  and  Minelli. — ^La  Radiologie  Medica,  Feb.,  1914.  Rev.  in  Arch,  of  Rontgen 
Ray,  April,  19 14. 

^*  Dodd,  W.  J. — Treatment  of  Acute  Rontgen  Ra}-  Dermatitis.  Amer.  Jour,  of  Ront- 
genology, Sept.  I,  1914,  Xo.  II. 

1'  Caldwell,  E.  W. — Treatment  of  Chronic  Rontgen  Dermatitis.  15th  Ann.  ^Meeting. 
Amer.  Rontgen  Ray  Soc,  Sept.  9-12,  1914. 

-"  Rutherford. — Radioactive  Substances  and  Their  Radiations.  Cambridge  University 
Press,  1913,  page  327. 

^^  Gudzent  and  Halberstaedter. — Deutsche  ^led.  Wochenschr.,  Mar.  26,  1914,  Xo.  13. 
page  633. 

Gexer.\l  Referenxes 

Behla,  Robert.^Die  Carcinoma  litteratur  Fine  ZusammensteUung  der  in-und  aus-landischen 
Krebsschrieben  bis,  1900,  Berlin,  Verlag  von  Richard  Schoetz,  1901. 

Williams,  W.  Roger. — The  Xatural  History  of  Cancer  with  Special  Reference  to  its  Causa- 
tion and  Prevention.     London,  WUliam  Heinemann,  1908. 

Bainbridge,  W.  S. — The  Cancer  Problem.     The  ^lacmillan  Co.,  X.  Y.,  1914. 


26 


DIVISION  VI 
Electrical  Injuries  and  Electrical  Shock 

BY  SIR  THOMAS  OLIVER,  Newcastle-upon-Tyne,  England 

Man's  equipment  has  in  recent  years  been  considerably  added  to  by  his 
mastery  over  electricity.  By  utiUzing  the  potent  fluid,  he  has  achieved 
results  which  have  transcended  the  imagination  of  his  forebears  of  a  century 
ago.  Distance  has  been  abridged  and  the  atmosphere  caused  inaudibly  to 
vibrate  with  the  winged  messages  of  human  thought.  While  electricity  has 
aided  civilization  and  been  of  the  greatest  assistance  to  man,  it  has  brought 
not  only  light  and  comfort  into  our  homes  but  dangers  as  well.  Electricity 
is  a  subtle  fluid;  we  can  store  it  and  control  its  flow,  although  we  know  little 
or  nothing  about  it.  In  this  article  we  are  concerned  solely  with  the  medical 
aspects  of  the  subject.  In  Europe  during  1910  there  were  200  deaths  caused 
by  electrical  shock.  Of  these  41  were  in  France  and  26  in  Great  Britain. 
In  America  the  number  was  probably  larger.  In  Great  Britain  according 
to  G.  Scott  Ram,^  H.  M.  Electrical  Inspector  of  Factories,  the  electrical 
accidents  for  1913  in  electrical  generating  stations  alone  were  65  with  two 
deaths.  Of  these  the  largest  number  31,  with  one  death,  occurred  during 
the  cleaning  and  repairing  of  "live"  switchboards  and  "live"  conductors. 
Twelve  accidents  occurred  at  switchboards  during  routine  work.  Of  the 
47.4  per  cent,  of  the  accidents  in  1913  occurring  during  cleaning  and  repair- 
ing, many  of  them,  with  care,  could  have  been  prevented.  Considering 
the  number  of  electrical  stations  in  Great  Britain  and  the  increasing  demands 
upon  their  production  the  number  of  electrical  accidents  in  the  United  King- 
dom is  not  considered  to  be  unduly  high.  To  the  accidents  already  recorded 
there  occurred  other  418  electrical  accidents  with  17  deaths  in  factories  other 
than  generating  stations.  Five  deaths  were  due  in  1913  to  conductors  having 
no  protection  at  all.  Trimming  of  arc  lights  was  the  cause  of  three  accidents 
with  one  death.  Of  20  fatalities  reported  to  the  Home  Ofiice  for  1913  as 
coming  under  the  Factory  and  Workshops  Act,  15  were  due  to  shock,  and 
12  of  these  15  were  due  to  alternating  currents  at  pressures  which  are  usually 
considered  low.  Two  of  the  deaths  were  the  result  of  burns.  In  one  of  the 
patients  blood  poisoning  followed  external  injuries. 

The  average  age  of  63  out  of  66  persons  injured  in  electrical  generating 
stations  was  just  over  20  years,  a  circumstance  which  shows  that  important 

402 


ELECTRICAL   INJURIES    AND    ELECTRICAL    SHOCK  403 

operations  such  as  testing  should  not  be  handed  over  to  apprentices  or  to 
pupils  who  have  little  experience  of  the  danger  which  is  incurred.  Many  of 
the  accidents  are  no  doubt  unavoidable,  but  many  can  be  prevented.  Some 
of  the  common  causes  of  accidents  are  mistakes  in  switching,  failure  to  dis- 
connect and  to  earth  test  leads  before  handling  them,  also  cheap  installation. 
Insulated  spanners  should  be  provided  by  employers,  also  India-rubber 
gloves..  The  absence  of  insulated  spanners  was  during  1913  in  Great  Britain 
the  cause  of  13  non-fatal  accidents.  The  nature  of  the  floor,  too,  in  which 
electricity  is  generated  is  of  importance.  In  one  instance  an  installation 
plant  was  found  in  a  building  with  an  iron  floor. 

Death  in  electric  shock  may  be  instantaneous.  Three  theories  at  least 
have  been  advanced  to  explain  the  fatal  event:  (i)  inhibition  of  the  respira- 
tory center  whereby  breathing  ceases  (D'Arsonval)  or  of  the  cardiac  center 
whereby  the  heart  stops  beating  (Bourrot);  (2)  sudden  and  complete  cardiac 
failure  (Tatum,  Prevost-BateUi) ;  (3)  hemorrhages  or  acute  disruption  of 
nerve  cells  (Donlin,  Icllinck). 

DeaHng  with  those  cases  where  death  does  not  supervene  until  several 
minutes  or  a  few  hours  after  the  accident.  Prof.  J.  P.  Langlois^  expresses  the 
opinion,  not  necessarily  his  own,  that  the  death  is  probably  to  be  explained 
by  bulbar  and  bulbo-spinal  paralysis  due  to  structural  alterations  of  the 
nerve  cells,  or  by  air  embohsm  consequent  upon  chemical  changes  in  the 
tissues  induced  directly  by  the  electrical  current  or  indirectly  through 
changes  in  the  trophic  action  of  nerves. 

Before  concluding  under  what  circumstances  an  electrical  current  is 
hkely  to  prove  dangerous  to  an  individual  brought  into  contact  with  it,  there 
are  a  few  things  which  have  to  be  thought  of.  There  is  the  current  itself, 
its  pressure  and  intensity,  its  nature,  e.g.,  alternating  or  continuous,  the  dura- 
tion of  the  contact,  resistance  of  the  conductor,  the  position  of  the  electrodes 
on  the  body  and  the  insulated  position  of  the  individual  at  the  time  he 
received  the  shock. 

By  the  term  voltage  we  mean  pressure  or  tension  and  by  amperage  in- 
tensity. It  is  difficult  to  say  what  voltage  is  fatal  to  man.  Under  some  cir- 
cumstances 240  volts  may  prove  fatal,  under  other  circumstances  1000  volts 
may  do  no  harm.  Much  depends  upon  the  conditions  under  which  the  cur- 
rent is  received.  Of  the  two  kinds  of  electric  current,  "continuous"  and 
''alternating,"  the  "alternating"  is  the  more  dangerous.  In  Great  Britain 
during  1 902-1 908  for  three  deaths  caused  by  continuous  currents  30  were 
due  to  alternating.  Circumstances  such  as  these,  however,  do  not  abso- 
lutely prove  that  alternating  currents  are  the  more  dangerous.  On  the  other 
hand,  the  British  Board  of  Trade  considers  alternating  currents  to  be  twice 
as  dangerous  as  continuous,  while  Weiss  regards  alternating  currents  as  four 
times  more  dangerous  than  continuous.  The  duration  of  the  contact  is  of 
importance.  Prevost  and  BateUi  state  that  the  continuous  current  requires 
less  time  than  the  alternating:  one-tenth  of  a  second  is  sufficient  for  the  con- 


404  ELECTRICAL   INJURIES    AND   ELECTRICAL    SHOCK 

tinuous  but  the  alternating  requires  three- tenths  of  a  second.  When  a  man 
comes  into  contact  with  live  metal  one  or  more  than  one  of  three  things 
happens:  (i)  he  is  burnt,  (2)  rendered  unconscious  and  is  convulsed  or  (3) 
he  is  killed  instantaneously.  Persons  apparently  killed  by  electric  shock 
may  be  restored  to  life  by  artificial  respiration.  An  electrocuted  person  is 
an  asphyxiated  person. 

The  consequences  of  the  passage  of  an  electrical  current  through  the  body 
are  proportional  to  the  quantity  of  current  passed  and  the  conditions  under 
which  contact  is  made.  A  moist  skin  intensifies  the  action  of  a  current.  A 
dry  skin,  on  the  other  hand,  may  prevent  serious  consequences.  Trotter 
found  when  wearing  a  pair  of  dry  boots  a  continuous  current  of  500  volts 
produced  hardly  any  effects.  He  took  a  walk  through  the  wet  streets  of 
the  town  and  found  that  with  the  same  current,  500  volts,  the  milliamperage 
had  risen  and  that  the  resistance  of  the  boots  had  fallen  15  per  cent.  Given 
fairly  good  contact  a  low  voltage  may  be  sufficient  to  throw  the  muscles  of 
the  body  into  such  a  state  of  tetanic  rigidity  that  it  is  impossible  for  the  indi- 
vidual to  breathe  and  to  relax  his  grasp  of  any  charged  metal  he  may  have 
taken  hold  of.  To  release  such  a  person  the  circuit  must  be  broken.  Since 
it  is  when  currents  enter  and  leave  the  body  that  effects  take  place,  the 
"making"  and  "breaking"  of  contact  are  the  dangerous  occasions.  Severe 
pain  may  be  the  result  of  the  entrance  of  an  electrical  current  owing  to  the 
strong  muscular  spasm  induced,  the  electrolytic  action  upon  nerves  or  of 
the  action  of  the  products  of  electrolytic  decomposition.  Should  the  indi- 
vidual not  be  immediately  thrown  into  a  state  of  unconsciousness  a  condition 
of  terror  is  produced  which  may  not  only  cause  the  victim  to  swoon  but  the 
mental  effect  may  be  such  as  to  cause  him  to  be  nervous  and  apprehensive 
for  months  afterward. 

Burning  is  one  of  the  visible  consequences  of  contact  with  electric  currents 
of  high  potentiality.  The  skin  is  charred;  if  open  wounds  have  been  caused 
they  are  irregular  and  deep;  the  bone  is  frequently  exposed;  the  sores  are  angry 
looking  and  are  disposed  to  slough.  They  are  painful  and  are  slow  to  heal, 
probably  owing  to  destruction  of  terminal  nerve  fibers.  Burns  occur  when 
the  action  of  the  current  has  been  local.  A  current  sufficient  to  cause  severe 
burns  might,  if  it  traversed  the  body,  cause  death.  There  are  cases  where, 
after  contact  with  high  electrical  currents,  little  or  no  effect-  is  seen  on  the 
skin  but  internal  damage  has  been  inflicted  upon  the  deep  tissues.  In  a  youth 
in  whom  this  had  taken  place  there  were  no  external  signs  of  injury,  but  as  a 
consequence  of  deeply  seated  effects  followed  by  gangrene  the  limb  had  to  be 
amputated  below  the  knee.  Later,  owing  to  sloughing  of  the  deeply  seated 
tissues  of  the  thigh,  the  remaining  portion  of  the  leg  had  to  be  amputated. 
A  definite  opinion  therefore  as  to  the  extent  of  the  injuries  cannot  always  be 
given  on  a  primary  and  superficial  examination.  One  man  whom  I  saw  in 
consultation  had,  while  crossing  an  electrified  railway,  inadvertently  touched 
a  live  rail  with  his  wet  boot.     He  was  immediately  thrown  down.     Fortu- 


ELECTRICAL   INJURIES    AND    ELECTRICAL    SHOCK  405 

nately  the  accident  occurred  close  to  a  signal  box  and  was  witnessed  by  the 
man  on  duty.  Leaving  the  box  and  putting  on  India  rubber  gloves  the  signal 
man  succeeded  in  removing  the  injured  person  from  the  rails.  Patient  was 
unconscious.  Help  was  secured  and  an  ambulance  obtained.  On  the  road 
home  the  injured  man  while  still  insensible  had  a  series  of  convulsions. 
Upon  a  cursory  examination  no  external  injuries  were  observed.  It  was  not 
until  his  home  was  reached  and  his  boots,  which  were  uninjured,  removed  that 
the  toes  and  front  of  each  foot  were  found  to  be  severely  burned.  In  an  hour 
or  two  consciousness  returned.  For  several  days  the  feet  were  extremely  ■ 
painful.  The  wounds  were  deep  and  angry  looking;  the  bones  of  the  big  toes 
and  of  the  metatarsus  were  exposed.  Healing  was  slow.  I  also  saw  a  youth 
aged  19,  the  subject  of  severe  burns,  who  received  a  shock  of  6000  volts,  alter- 
nating current,  without  fatal  consequences.  His  right  hand  was  almost 
burned  through.  The  hand  was  charred,  irritable  looking  and  disposed  to 
slough.  The  outer  three  fingers  were  destroyed.  In  addition  there  were 
acutely  inflamed  and  blistered  patches  on  the  lower  part  of  the  right  forearm, 
also  blisters  on  the  soles  of  the  feet.  Patient's  boots  were  uninjured.  This 
youth  was  working  on  the  three-phase  system;  he  had  touched  one  wire  and 
then  another  without  any  consequences,  but  on  touching  the  third  wire  he  fell 
and  became  unconscious.     He  was  standing  on  a  concrete  floor  at  the  time. 

One  of  the  worst  cases  I  have  seen  was  that  of  a  young  laborer  admitted 
into  the  Royal  Victoria  Infirmary,  Newcastle,  under  the  care  of  my  surgical 
colleague,  Professor  H.  B.  Angus.  The  man  had  accidentally  made  contact 
with  a  current  of  20,000  volts.  I  saw  patient  2  hours  after  the  accident.  He 
was  unconscious  but  kept  rolling  about  in  bed  in  an  extremely  restless  manner. 
His  pupils  were  widely  dilated.  There  were  several  large  burns  on  the  trunk, 
front  and  back,  also  on  the  limbs.  There  was  a  large  circular  burn  on  the  back 
of  the  head  with  exposure  of  the  occipital  bone.  He  died  7  hours  after  receiving 
the  shock.  At  the  autopsy,  40  hours  after  death,  there  were  hemorrhages  in 
the  occipital  lobe  of  the  brain,  numerous  minute  hemorrhages  on  the  visceral 
layer  of  the  pericardium;  liver,  kidneys  and  portions  of  the  lungs  were  deeply 
congested. 

In  both  of  these  cases  the  voltage  was  high.  As  an  illustration  of  a  com- 
paratively low  pressure — no  volts — -causing  death,  the  following  note,  taken 
from  the  pen  of  Dr.  Fleury^  of  Versailles,  may  be  quoted.  It  is  the  case  of  a 
healthy  married  woman  aged  35  who  died  in  25  seconds  after  receiving  the 
shock.  She  was  in  the  act  of  having  her  usual  daily  bath.  The  bath,  which 
was  made  of  enamelled  iron,  was  closed  by  a  metallic  plug  placed  in  the  middle 
of  the  floor  of  the  bath.  The  plug  was  attached  to  a  chain  and  to  this  a  float. 
An  electric  bell  communicator,  composed  of  a  chain  of  metallic  rings  ending  in 
a  porcelain  handle,  was  fixed  to  the  wall  close  to  the  bath.  Madame  C  after 
having  been  attended  to  by  her  maid  was  left  to  complete  her  bath.  Hardly 
had  the  maid  left  when  hearing  a  cry  she  rushed  back  to  the  bathroom  where 
she  found  her  mistress  with  her  head  out  of  the  water  but  fallen  forward, 


4o6  ELECTRICAL   INJURIES    AND   ELECTRICAL    SHOCK 

the  face  cyanosed  and  both  hands  spasmodically  grasping  the  chain  of  the 
electric  bell.  In  attempting  to  remove  the  chain  the  maid  herself  received 
a  severe  electric  shock.  Madam  C  was  dead.  All  efforts  to  restore  her  proved 
unavailing.  The  whole  tragedy  was  enacted  within  25  seconds.  It  is  pre- 
sumed that  Madam  C  must  have,  when  in  the  bath,  formed  an  electric  circuit 
between  the  left  hip  which  was  resting  on  the  metal  plug  in  the  bath  and  the 
chain  of  the  electric  bell  which  she  was  grasping  in  her  hand  at  the  time  of  her 
death.  The  current  when  tested  was  found  to  be  capable  of  lighting  a  lamp 
of  no  volts.  On  examining  the  body  after  death  two  small  hemorrhages 
were  observed  on  the  upper  and  posterior  part  of  both  arms  near  the  axillae, 
and  on  the  left  hip  there  were  a  few  blisters  filled  with  blood.  At  the  post- 
mortem examination  nothing  special  was  found  in  the  heart,  pericardium,  the 
abdomen  and  brain,  while  beyond  a  few  limited  areas  of  congestion  and  a  few 
old  pleuritic  adhesions  the  lungs  presented  nothing  abnormal.  The  appear- 
ances generally  speaking,  but  especially  those  presented  by  the  heart,  were  those 
of  asphj'xia.  The  left  ventricle  was  empty,  the  right  ventricle  was  filled  with 
dark  non-coagulated  blood.  The  low  voltage,  no,  was  at  first  thought  to  be 
an  unlikely  cause  of  death,  and  yet  everything  pointed  to  death  from  electric 
shock. 

As  already  stated,  pressure  or  tension,  that  is  the  number  of  volts,  is  one 
of  the  factors  to  be  considered  in  electrical  injuries.  Prevost  and  Batelli  of 
Geneva  ar^  of  the  opinion  that  voltage  below  100  is  only  slightly  dangerous, 
and  yet  death  has  followed  contact  with  a  current  of  75  volts.  The  intensity 
of  an  electrical  current  is  represented  by  and  for  the  purpose  of  illustration  is 
regulated  much  in  the  same  way  as  the  flow  of  water  when  a  tap  is  turned  on. 
The  intensity  is  calculated  in  amperes.  From  a  medical  point  of  view  what 
is  important  is  the  intensity  of  the  current  as  it  traverses  the  body  at  the  time 
of  the  accident.  A  current  of  25  milHamperes  is  bearable;  one  between  25  and 
60  is  capable  of  doing  considerable  harm;  beyond  this  the  danger  increases 
proportionally,  death  almost  always  supervening  if  the  intensity  reaches  100 
milHamperes. 

The  resistance  offered  by  the  body  to  the  passage  of  the  current  has  also 
to  be  considered.  A  relationship  is  thus  established  between  the  three 
factors:  tension  (£),  intensity  (/),  and  resistance  (R).  This,  known  as  Ohm's 
law,  is  expressed  thus: 

by  which  is  meant  that  the  intensity  in  amperes  is  proportional  to  the  ten- 
sion in  volts  and  is  inversely  proportional  to  the  resistance  in  ohms.  In 
other  words,  the  feebler  the  resistance  offered  by  the  subject  the  greater  will 
be  the  intensity  in  amperage  and  the  more  likely  will  the  subject  be  affected 
by  the  electrical  current.  Such  other  factors  as  already  mentioned,  viz., 
the  extent  of  the  surface  of  the  body  exposed   to   the   current   and   the 


I 


ELECTRICAL   INJURIES    AND    ELECTRICAL    SHOCK  407 

dryness  or  humidity  of  the  skin,  cannot  be  ignored.  A  similar  remark 
applies  to  the  period  of  time  during  which  the  current  passes.  Resistance 
becomes  diminished  as  the  current  traverses  a  body  and  as  a  consequence 
the  intensity  in  amperage  rises.  In  illustration  of  this,  Fleury  in  his  experi- 
ments found  that  while  a  dog  could  resist  a  current  of  4000  volts  during  2 
seconds,  it  succumbed  to  contact  with  no  volts  applied  for  19  seconds. 

The  direction  of  the  current,  too,  is  of  importance.  Should  the  heart 
lie  in  the  path  of  the  current,  danger  to  life  is  enormously  increased;  hence 
the  risk  of  a  current  when  it  is  passed  through  hands  to  feet  and  vice  versa. 
The  following  cases  recorded  by  Fleury  are  two  of  the  fatalities  which  have 
been  caused  by  what  might  be  considered  low  voltages.  A  youth  received 
a  shock  of  125  volts;  he  fell  to  the  ground  and  in  rolling  over  caused  the 
electric  wire  to  encircle  a  metal  bucket  which  was  being  carried  by  a  woman 
standing  close  by.  The  woman  was  killed  instantaneously.  A  female 
cook  in  Geneva  attempted  while  one  of  her  wet  hands  held  an  electric  lamp 
to  draw  water  from  a  lead  pipe  with  the  other.  She  had  hardly  touched  the 
tap  when  she  received  a  shock  from  a  current  of  no  volts  and  succumbed 
almost  immediately.  Since  death  has  been  caused  by  voltages  of  no  to 
170  in  the  case  of  persons  completing  circuit  through  touching  electric  lamps 
in  dwelling  houses,  people  ought  to  be  forewarned  of  the  dangers. 

CAUSE  OF  DEATH  IN  ELECTRIC  SHOCK" 

In  order  to  ascertain  the  cause  of  death  in  electric  shock  I  carried  out  a 
few  years  ago  a  series  of  experiments  with  my  colleague.  Prof.  R.  A.  Bolam, 
upon  anaesthetized  dogs  and  rabbits,  the  continuous  current  being  employed. 
Two  of  the  main  theories  of  the  cause  of  death  are:  (i)  arrest  of  respiration; 
(2)  stoppage  of  the  heart.  In  order,  to  ascertain  which  of  these  two  is  the 
cause  of  death,  we  had  arranged  before  bringing  the  animals  into  contact 
with  the  electrical  current  that  a  record  of  the  blood  pressure  and  respiratory 
movements  should  be  taken  simultaneously.  In  this  way  we  sought  to 
demonstrate  how  the  heart  and  respiration  became  aflfected  when  high 
electrical  currents  are  passed  through  the  body.  On  making  electrical  con- 
tact the  "animal  would  at  once  be  thrown  into  an  attitude  of  opisthotonos, 
the  muscles  generally  throughout  the  body  becoming  rigid.  The  lever  of 
the  apparatus  recording  the  respiratory  movements  would  be  suddenly  and 
violently  raised,  while  the  other,  indicating  the  blood  pressure  and  beat  of 
the  heart,  would  also  be  suddenly  lifted  owing  to  general  arterial  constriction. 
Momentarily  maintained  in  these  positions  the  levers  would  gradually  fall 
so  that  their  oscillations  covered  a  shorter  range.  On  breaking  contact,  the 
respiration  would  become  deeper  and  quicker  than  it  was  before  the  shock. 
Thereafter,  within  a  few  seconds,  breathing  and  the  heart's  beat  would  be- 
come normal.  In  dogs  which  succumbed  rapidly  to  electrical  shock  there 
was  the  same  initial  respiratory  spasm  with  a  sudden  rise  of  arterial  pressure 


4o8         ELECTRICAL  INJURIES  AND  ELECTRICAL  SHOCK 

followed  by  an  immediate  fall.  A  few  further  oscillations  of  the  lever  mark- 
ing the  arterial  pressure  would  be  observed,  and  then  a  sudden  fall  of  the  lever 
would  occur  indicating  that  the  heart  had  ceased  beating.  In  some  of  the 
electrocuted  animals  respiration  continued  for  several  seconds  after  the  heart 
had  stopped.  In  other  experiments  with  240  volts,  continuous  current, 
death  in  electrical  shock  was  of  cardiac  origin  and  not  respiratory.  Where  an 
electrical  current  was  not  sufi&cient  to  kill  a  dog  immediately,  the  heart's 
beat  would  be  momentarily  delayed,  then  quickened,  during  which  the  cardiac 
sounds  could  be  heard  quite  well,  but  when  currents  of  higher  potential  were 
employed  the  sounds  of  the  heart  on  contact  being  made  would  cease  almost 
immediately  while  the  respiration  continued.  If  artificial  respiration  was 
not  adopted  the  breathing  gradually  ceased  and  the  beat  of  the  heart  did 
not  return,  the  pupils  dilated,  mucus  flowed  from  the  mouth  and  in- 
creasing pallor  stole  over  the  body. 

On  exposing  the  heart  of  anaesthetized  dogs  and  inserting  a  canula  into  the 
trachea  in  order  to  carry  on  artificial  respiration,  we  had  ocular  demonstra- 
tion that  it  was  the  heart  which  was  primarily  arrested  as  a  consequence  of 
the  passage  through  the  body  of  continuous  electrical  currents  of  240  volts. 

Professor  A.  M.  Bleile  of  Ohio  State  University,  as  the  result  of  experi- 
ments, concluded  that  death  in  electrical  shock  is  due  to  the  current  produc- 
ing through  the  nervous  system  constriction  of  the  arteries  whereby  there  is 
created  a  mechanical  impediment  to  the  flow  of  blood  which  the  heart  is 
unable  to  overcome.  Bleile  found  that  when  drugs  were  given  beforehand 
to  counteract  the  contraction  of  the  arteries  higher  voltages  could  be  borne, 
Bolam  and  I  came  to  a  similar  conclusion.  When  we  caused  anaesthetized 
animals  to  inhale  amyl  nitrite  before  making  the  electrical  contact  we 
noticed  that  stronger  currents  could  be  borne.  In  our  experiments  we  found 
that  the  heart  was  the  organ  primarily  affected  even  when  atropine  had  been 
previously  administered  to  abolish  the  influence  of  the  vagus.  Whether 
the  heart  muscle  is  paralyzed  by  the  electrical  current,  destroyed  by  the  mo- 
lecular changes  produced  by  the  current,  or  brought  to  a  standstill  by  the 
enormous  resistance  of  the  constricted  arteries  above  referred  to  I  am  not  in 
a  position  to  say.  Not  only  is  there  no  definite  relation  between  the  size 
and  weight  of  an  animal  and  the  strength  of  the  current,  but  a  current  which 
is  passed  for  a  few  seconds  one  day  without  bad  effect  may  on  another  kill 
the  animal  in  2  or  3  seconds. 

Fleury  found  in  dogs,  when  the  milliamperage  rose  to  70-80,  that  within 
5  seconds  the  heart  showed  fibrillary  tremor.  When  the  current  was  cut 
off  there  was  marked  fibrillation  of  the  ventricles  of  the  heart  and  respiration 
which  had  ceased  recommenced  and  shortly  afterward  gradually  died  away. 
To  explain  death  in  electric  shock  Dr.  G.  Weiss  advances  the  following  theory: 
Under  the  influence  of  alternating  currents  the  muscles  of  the  body  are  thrown 
into  a  state  of  tetanus,  organic  combustion  is  enormously  increased,  there  is 
an  imperative  necessity  on  the  part  of  the  animal  to  absorb  oxygen  and  to 


ELECTRICAL  INJURIES  AND  ELECTRICAL  SHOCK         409 

exhale  carbon  dioxide.  Respiration  is  embarrassed  owing  to  tetanic  rigidity 
of  the  thorax  and  as  a  consequence  asphyxia  develops  shortly.  Fleury, 
basing  his  opinion  upon  the  fatal  case  alluded  to  in  the  text,  regards  the  mech- 
anism of  death  in  electric  shock  as  complex;  there  are  asphyxia  and  paralysis 
of  the  heart.  When  these  occur  death  is  rapid.  When  death  is  not  instan- 
taneous he  is  of  the  opinion  that  death  is  brought  about  by  fibrillary  tremor 
of  the  heart. 

J.  L.  Prevost  and  F.  Battelli  of  Geneva  found  with  alternating  currents 
of  low  tension  that  the  heart  was  thrown  into  a  condition  of  fibrillary  tremor. 
With  a  tension  of  20-40  volts  the  heart  became  paralyzed  but  respiration 
continued.  When  high  alternating  currents  of  240-600  volts  were  employed 
the  heart  and  respiration  ceased  simultaneously.  Prevost  and  Battelli  found 
in  using  continuous  currents  that  the  results  were  practically  the  same  as 
with  alternating,  there  being,  however,  this  important  difference,  that  when 
continuous  currents  were  employed  voltages  less  than  50  did  not  produce 
fibrillary  arrest  of  the  heart's  action,  but  alternating  currents  of  only  10  volts 
induced  fibrillary  tremor  followed  by  stoppage  of  the  beat  of  the  heart. 

There  is  a  general  consensus  of  opinion  that  electrical  currents  below 
150  volts  if  they  prove  fatal  cause  death  by  stopping  the  beat  of  the  heart 
which  had  been  previously  thrown  into  a  condition  of  fibrillary  tremor. 
High  tension  currents,  e.g.,  1200  volts,  leave  the  heart  intact,  but  they  arrest 
breathing  and  induce  asphyxia  which  if  not  treated  may  end  in  death.  With 
voltages  between  these  two,  sometimes  the  heart  ceases  beating,  sometimes 
respiration  is  arrested  or  the  two  events  occur  simultaneously.  Experience 
shows  that  such  low  voltages  as  75-100  are  not  free  from  danger, 

PATHOLOGY 

If  the  body  is  examined  shortly  after  death  there  is  usually  rigidity  of  the 
muscles.  There  may  or  may  not  be  external  signs  of  burning.  The  body 
may  be  pale  or  livid.  On  opening  the  body  cavities  the  abdominal  veins 
are  found  filled  with  dark  Hquid  blood  and  the  viscera  are  observed  to  be 
congested.  The  right  ventricle  of  the  heart  is  flaccid  and  the  left  ventricle 
hard  and  tense.  In  the  right  side  of  the  heart  the  blood  is  dark  and  Hquid; 
the  left  ventricle  is  practically  empty  but  the  left  auricle  usually  contains 
dark  liquid  blood.  The  absence  of  coagulation  of  the  blood  is  noteworthy. 
This  is  of  great  significance,  but  it  is  not  absolutely  diagnostic  as  in  some  of 
my  experiments  I  found  coagula  in  the  right  side  of  the  heart.  Beyond  a 
few  ecchymoses  and  signs  of  congestion  the  lungs  may  show  no  special  feature. 
Generally  speaking,  the  signs  are  those  of  asphyxia.  The  brain  and  spinal 
cord  may  be  congested  or  they  may  show  no  abnormality.  The  blood  on 
spectroscopic  examination  was  found  to  contain  in  some  of  my  cases  both 
oxyhemoglobin  and  reduced  hemoglobin.  Usually  the  pupils  are  dilated. 
On  examining  the  brain  of  one  of  the  patients  killed  by  currents  of  high  poten- 


4IO  ELECTRICAL   INJURIES    AND   ELECTRICAL    SHOCK 

tiality  there  were  observed  minute  hemorrhages  due  to  rupture  of  small 
vessels  in  the  cortex  and  white  matter.  The  blood  showed  evidences  of 
hemolysis.  Drs.  F.  W.  Mott  and  Schuster,  who  were  kind  enough  to  examine 
sections  of  the  brain  microscopically  for  me,  found  chromolytic  changes  in 
the  brain  cells.  Similar  changes  were  noticed  in  the  cells  of  the  rnedulla 
oblongata. 

As  bearing  upon  the  lesions  found  in  the  brain,  mention  must  be  made 
of  the  important  contribution  to  this  subject  by  Drs.  E.  A.  Spitzka*  and  H.  E. 
Raschi  of  Jefferson  Medical  College,  Philadelphia.  Their  findings  are  of 
importance  since  the  lesions  described  obtained  in  the  brain  and  spinal  cord 
of  five  crii^inals  who  had  been  electrocuted — the  voltages  varying  from 
1750  to  1850,  amperage  8  to  11  and  the  contacts  two  to  four.  The  brain 
in  each  instance  was  removed  15  minutes  after  death  so  that  there  was  no 
time  for  post-mortem  decomposition  to  have  set  in.  The  parts  of  the  brain 
examined  were  the  mid-brain  and  the  pons  oblongata.  At  the  levels  men- 
tioned Spitzka  and  Raschi  found  peculiar  areas,  circular  in  outline  and  vary- 
ing in  size  from  25  to  300  /x.  They  consisted  of  two  portions — a  central 
rarified  zon€  and  a  peripheral  condensed  zone.  The  areas  contained  a 
blood-vessel  surrounded  by  a  delicate  reticulum,  the  fibrils  of  which  were 
radically  directed.  Nuclei  were  observed  along  their  course.  The  peripheral 
zone  immediately  in  contact  with  the  central  stained  more  readily  and  deeply 
than  the  external.  In  the  peripheral  zone  there  was  an  absence  of  nuclei. 
In  the  upper  part  of  the  spinal  cord  close  to  the  pyramidal  decussation  the 
myelin  did  not  stain  well  with  hematoxylin  and  eosin,  Van  Gieson  or  Weigert's 
staining  fluid.  Along  the  course  of  the  blood-vessels  were  bead-like  expan- 
sions like  clear  beads  adherent  to  the  wall  of  the  vessel.  The  writers  are 
'  of  the  opinion  that  the  bead-like  expansions,  the  condensation  zone  limiting 
these,  the  radically  disposed  fibers  and  the  torn  tissues  indicate  a  sudden 
liberation  of  gas  bubbles  due  to  the  electrolytic  properties  of  the  current 
seeking  paths  of  least  resistance  along  the  course  of  the  blood-vessels. 

Treatment.^ — ^ Where  the  electrical  shock  has  been  slight  and  the  individual 
has  not  been  rendered  unconscious  no  treatment  is  called  for.  The  effects 
pass  away  almost  immediately.  Some  persons  thus  injured  remain  nervous 
for  several  days  or  weeks  afterward.  Burns  or  wounds  caused  by  electricity 
must  be  treated  on  ordinary  surgical  lines.  Where  the  heart  has  ceased  beat- 
ing and  respiration  has  been  arrested  the  treatment  which  is  most  hkely  to 
give  satisfactory  results  is  artificial  respiration.  It  matters  little  so  far  as  this 
matter  of  treatment  is  concerned  whether  death  is  primarily  of  cardiac  or 
respiratory  origin.  Artificial  respiration  must  be  carried  on  for  a  considerable 
time.  In  the  case  of  a  man  who  had  accidentally  been  electrocuted  and  who 
was  seen  shortly  afterward  by  a  medical  man,  artificial  respiration  was  under 
his  supervision  carried  on  for  at  least  half  an  hour  without  any  response. 
Believing  that  apparent  death  had  been  actual  the  medical  man  pronounced 
life  to  be  extinct,  and  left  the  place.     The  workingmen  in  the  factory  of 


^ 


ELECTRICAL   INJURIES   AND   ELECTRICAL   SHOCK  411 

their  own  accord  carried  on  artificial  respiration  for  a  considerable  time  after 
the  doctor  left  and  were  rewarded  about  an  hour  after  the  accident  by  seeing 
their  comrade  restored  to  Hfe,  Twice  Bolam  and  I  succeeded  in  resuscitating 
a  dog  whose  heart  had  ceased  beating  once  for  13  minutes  and  on  the  second 
occasion  for  8.  The  heart  was  exposed  to  view  so  that  we  could  follow  the 
events  whiph  took  place.  The  heart  had  become  rapidly  distended  with 
blood  so  as  to  bulge  out  the  pericardium  and  had  become  perfectly  motionless 
after  having  passed  through  a  stage  of  fibrillary  tremor.  By  persisting  in 
artificial  respiration,  aided  subsequently  by  occasional  spontaneous  inspira- 
tions, also  through  rhythmic  traction  of  the  tongue,  the  contents  of  the  right 
side  of  the  heart  were  gradually  aspirated  into  and  through  the  lungs  and  the 
auricular  beats  were  reestablished,  at  first  irregularly  and  feebly.  By  de- 
grees the  auricular  pulsations  became  stronger  and  passed  over  into  the  ven- 
tricles so  that  after  13  minutes,  during  which  the  left  ventricle  had  remained 
irresponsive,  Bolam  and  I  had  the  satisfaction  of  seeing  the  normal  beat  of  the 
heart  restored,  the  pulmonary  and  general  circulation  reestablished  and  life 
return.  Leduc  points  out  that  when  an  animal  has  been  apparently  killed  by 
electricity  and  the  heart  has  ceased  beating,  the  animal  can  usually  be  re- 
stored to  life  by  applying  the  same  amount  of  current  to  the  body,  for  since 
this  produces  immediate  contraction  of  the  muscles  of  the  body,  including 
those  of  inspiration,  artificial  respiration  is  to  some  extent  aided  and  can  be 
proceeded  with.  There  is  a  belief  on  the  part  of  some  physiologists,  where 
death  is  of  cardiac  origin  and  has  been  preceded  by  fibrillary  contraction,  that 
neither  artificial  respiration  nor  massage  of  the  heart  is  of  the  slightest  value  in 
restoring  the  victim.  Artificial  respiration  upon  one  of  our  animals  in  whom 
fibrillary  tremor  had  occurred  was,  as  already  indicated,  successful,  but  set- 
ting that  aside  for  the  moment,  yet  still  insisting  that  artificial  respiration  is  a 
mode  of  treatment  well  worthy  of  adoption,  the  following  may  be  not  less 
successful.  It  has  been  demonstrated  that  where  a  dog  has  been  killed  by 
electric  currents  of  high  potentiality  and  the  heart  still  shows  signs  of  fibrillary 
tremor,  the  application  directly  to  the  heart  of  an  electrode  carrying  a  still 
larger  current  than  the  one  which  apparently  proved  fatal  will  cause  cessation 
of  the  fibrillary  movements  and  on  withdrawal  of  the  current  the  heart  will 
resume  its  rhythmic  beats  again.  In  some  cases  the  sufferer  is  killed  outright 
so  that  all  attempts  at  resuscitation  fail.  Under  all  circumstances,  however, 
where  persons  are  the  subjects  of  apparent  death  from  electrical  shock  arti- 
ficial respiration  should  be  resorted  to  and  continued  for  at  least  an  hour. 
Workmen  in  their  efforts  to  rescue  a  comrade  should  be  provided  with  India- 
rubber  gloves  and  insulated  spanners,  or  where  these  are  unattainable  should 
wrap  thick,  coarse,  dry  clothing  round  their  hands,  for  otherwise  in  their 
attempts  to  rescue  a  stricken  fellow-workman  they  themselves  may  receive  a 
fatal  shock.  To  cut  a  live  wire  long  shears  with  wooden  handles  should  be 
used. 


412  ELECTRICAL   INJURIES    AND   ELECTRICAL    SHOCK  " 

ELECTRICA  OPHTHALMIA 

Electricity  is  used  in  the  welding  of  metals.  In  this  operation  the 
brightness  of  the  glare  causes  injury  to  the  eyesight.  Dr.  George  L.  Apfel- 
bach*  draws  attention  to  a  morbid  eye  condition,  electrica  ophthalmia,  caused 
by  electric  hght  rays.  In  these  rays  the  ultra-\'iolet  predominate.  The 
signs  and  symptoms  of  the  malady  are  conjunctivitis,  photophobia  and  pro- 
fuse secretion  of  tears  with  occasionally  loss  of  vision.  Such  electrical  flashes 
as  cause  eye  troubles  are  usually  due  to  short  circuiting,  loose  electrical  con- 
nections and  strong  arcs.  Dr.  Apfelbach-cites  50  cases  of  electrica  ophthalmia 
occurring  in  a  large  iron  works.  It  is  the  actinic  rays  present  in  electrical 
flashes  which  do  harm.  Electricians  exposed  to  accidental  short  circuiting 
often  suffer  from  temporary  blindness  of  i  or  2  hours'  duration.  In  some 
people  the  eyes  become  bloodshot  and  the  eyelids  swollen.  Photophobia 
is  a  common  symptom.  Patients  feel  as  if  the  eyes  contained  sand.  Ker- 
atitis and  iritis  are  not  unknown.  A  similar  remark  applies  to  pigment 
changes  in  the  retinae.  As  a  rule  the  prognosis  is  good.  A  more  detailed 
statement  of  the  harmful  effects  of  exposure  to  electric  light  and  to  electric 
welding  is  given  in  my  book  "Dangerous  Trades  "  by  the  late  Mr.  Simeon 
Snell  of  Shefiield.  The  apphcation  of  a  few  drops  of  a  4  per  cent,  solution  of 
cocaine  to  the  eyes  gives  relief  to  pain.  Irrigation  of  the  eyes  with  weak 
boracic  lotion  may  be  necessary,  followed  later  by  the  instillation  into  the 
eyes  of  a  few  drops  of  argyrol — 25  per  cent,  solution.  If  photophobia  con- 
tinues, smoked  glasses  ought  to  be  worn.  Dr.  Apfelbach  states  that  in  some 
of  the  large  steel  works  electrica  ophthalmia  is  prevented  by  the  men  wearing 
glasses  made  up  of  two  blue  glasses  with  a  red  one  between.  By  this  means 
the  strong  actinic  or  ultra-violet  rays  are  prevented  filtering  through. 

In  all  generating  stations  and  in  factories  wherein  electricity  is  used  on  a 
large  scale,  danger  signals  should  be  employed  to  avert  the  disasters  alluded 
to  in  the  text,  while  all  workmen  likely  to  be  brought  into  contact  either  with 
live  metal  itself  or  with  fellow-workmen  injured  by  electrical  contact  should 
be  instructed  in  rescue  work  and  in  the  precautions  necessary  for  self- 
protection. 

REFERENCES 

1  Annual  Report  of  the  Chief  Inspector  of  Factories,  1913. 

2  Revue  Generale  die  Sciences,  Apr.  30,  1913,  page  294. 
'  Annales  d'Hygiene  Publique,  Apr.,  1914. 

''  The  American  Journal  of  Medical  Sciences,  Sept.,  1912,  page  341. 
5  Factory  Inspectors  Bulletin,  State  of  Illinois,  Apr.  14,  1914. 


ELECTRICAL    INJURIES    AND    ELECTRICAL    SHOCK 


413 


RESUSCITATION  FROM  ELECTRIC  SHOCK 

rules  recommended  by 
Commission  on  Resuscitation  from  Electric  Shock 

Representing 

The  American  Medical  Association 

The  National  Electric  Light  Association 

The  American  Institute  of  Electrical  Engineers 


DR.  W.  B.  CAXXOX,  Chairman, 

Professor  of  Physiology,  Harvard  University 

DR.  YANDELL  HENDERSON 

Professor  of  Phxsiology,  Yale  University 

DR.  S.  J.  MELTZER 

Head  of  Department  of  Physiology  and  Pharma- 
cology Rockefeller  Institute  for  Medical  Research. 

DR.  EDW.  ANTHONY  SPITZKA 
Formerly  Director  and  Professor  of  General  Anat- 
omy, Daniel  Baugh  Institute  of  Anatomy,  Jeffer- 
son Medical  College. 


DR.  GEORGE  W.  CRILE 

Prof,  of  Surgery,  Western  Reserve  University 
MR.  W.  C.  C.  EGLIN 

Past-President,   National  Electric  Light  Ass'n 
DR.  A.  E.  KENNELLY 

Professor     of    Electrical     Engineering,     Harvard 

University 
DR.  ELIHU  THOMSON 

Electrician,  General  Electric  Company 
MR.  W.  D.  WEAVER,  Secretary 

Editor,  Electrical  World. 


Copyright,  1912,  by 
National  Electric  Light  Association 

FOLLOW  THESE  INSTRUCTIONS  EVEN  IF  VICTIM  APPEARS  DEAD 

I.  Immediately  Break  the  Circuit 

With  a  single  quick  motion  free  the  victim  from  the  current.  Use  any  dry  non-conductor 
(clothing,  rope,  board)  to  move  either  the  victim  or  the  wire.  Beware  of  using  metal  or  any 
moist  material.  While  freeing  the  victim  from  the  live  conductor  have  every  effort  also 
made  to  shut  ofif  the  current  quickly. 


Fig.  27. — Expiration;  pressure  on. 


n.  Instantly  Attend  to  the  Victim's  Breathing 

I .  As  soon  as  the  victim  is  clear  of  the  conductor,  rapidly  feel  with  your  finger  in  his  mouth 
and  throat  and  remove  any  foreign  body  (tobacco,  false  teeth,  etc.).  Then  begin  artificial 
respiration  at  once.  Do  not  stop  to  loosen  the  victim's  clothing  now;  every  moment  of 
delay  is  serious.     Proceed  as  follows: 


414 


ELECTRICAL  INJURIES  AND  ELECTRICAL  SHOCK 


(a)  Lay  the  subject  on  his  belly,  with  arms  extended  as  straight  forward  as  possible, 
and  with  face  to  one  side,  so  that  nose  and  mouth  are  free  for  breathing  (see  Fig.  27).  Let 
an  assistant  draw  forward  the  subject's  tongue. 

{b)  Kneel  straddling  the  subject's  thighs  and  facing  his  head;  rest  the  palms  of  your 
hands  on  the  loins  (on  the  muscle3  of  the  small  of  the  back),  with  fingers  spread  over  the 
lowest  ribs,  as  in  Fig.  27. 

(c)  With  arms  held  straight,  swing  forward  slowly  so  that  the  weight  of  your  body  is  • 
gradually,  but  not  violently,  brought  to  bear  upon  the  subject  (see  Fig.  28).     This  act  should 
take  from  2  to  3  seconds. 

(d)  Then  immediately  swing  backward  so  as  to  remove  the  pressure,  thus  returning  to  the 
position  shown  in  Fig.  27. 

(e)  Repeat  deliberately  12  to  15  times  a  minute  the  swinging  forward  and  back — a  com- 
plete respiration  in  4  or  5  seconds. 


Fig.  28. — Inspiration;  pressure  off. 

(/)  As  soon  as  this  artificial  respiration  has  been  started,  and  while  it  is  being  continued, 
an  assistant  should  loosen  any  tight  clothing  about  the  subject's  neck,  chest,  or  waist. 

2.  Continue  the  artificial  respiration  (if  necessary,  2  hours  or  longer),  without  inter- 
ruption, until  natural  breathing  is  restored,  or  untU  a  physician  arrives.  If  natural  breath- 
ing stops  after  being  restored,  use  artificial  respiration  again. 

3.  Do  not  give  any  liquid  by  mouth  until  the  subject  is  fully  conscious. 

4.  Give  the  subject  fresh  air,  but  keep  him  warm. 

HI.    Send  for  Nearest  Doctor  as  Soon  as  Accident  is  Discovered 

The  following  Doctors  are  recommended: 

Name  Address  Telephone     Call 


The  prone -pressure  method  of  artificial  respiration  described  in  the  rules  (Section  II)  is  equally 
applicable,  after  clearing  the  mouth  and  throat  of  froth,  to  the  resuscitatoin  of  the  apparently  drowned, 
and  also  to  cases  of  suspended  respiration  due  to  inhalation  of  gas  or  to  other  causes. 


PART  II 

ETIOLOGY  AND  PROPHYLAXIS  OF  OCCUPATIONAL 
DISEASES.     VOCATIONAL  HYGIENE 


Photograph  supphed  by  Dr.  He 


jn   through  the  courtesy 
Telegraph  Company. 


u£  the  Americau  Telephuiic  and 


Fig.  29. — Anti-asphyxiator  for  supplying  fresh  air  to  cablemen  while  at  work  in  the 
cable  vaults,  which  are  below  the  street  surface.  This  is  a  mask  which  fits  tightly  over 
the  nose  and  mouth,  having  two  valves  which  work  automatically  as  the  man  breathes; 
one  valve  supplies  the  fresh  air  as  he  inhales  and  the  other  carries  out  the  vitiated  air  as 
he  exhales.  The  intake  is  set  up  beside  the  manhole,  pointed  in  the  direction  from  which 
the  wind  is  blowing,  and  connected  to  the  mask  by  rubber  pipe.  Cablemen  have  been 
known  to  work  every  day  for  over  a  week  in  gaseous  manholes  with  the  aid  of  this  device. 


416 


DIVISION  I 
Etiology  and  Prophylaxis  of  Occupational  Diseases 

BY  GEORGE  M.  KOBER,  M.  D..  Washington,  D.  C. 

Health  is  the  chief  asset  of  the  workingman,  and  no  greater  calamity 
can  befall  him  than  when  his  earning  capacity  is  impaired  or  arrested  by 
reason  of  sickness  or  disability.  It  means  in  many  instances  the  utter  finan- 
cial ruin  of  the  family,  and  is  doubtless  one  of  the  most  potent  causes  of 
poverty  and  distress.  ^lany  diseases  are  incident  to  occupation  and  en- 
vironment and  industrial  efficiency,  and  earning  power  can  be  promoted  by 
appropriate  safeguards  and  adequate  protection  of  those  engaged  in  gainful 
occupations. 

Definitions.— Hfiseases  of  occupation  may  be  defined  as  injuries  and  dis- 
turbances of  health  contracted  in  industrial  pursuits,  and  other  vocations 
in  fife,  as  a  result  of  exposure  to  toxic  agents,  infectious  organisms  or  other 
conditions  inimical  to  health. 

These  diseases  may  be  acute  or  chronic  and  vary  in  intensity  and  duration 
from  the  acute  and  fatal  attacks  of  asphyxia,  caused  by  suffocating  gases, 
to  the  slow  and  insidious  forms  of  industrial  tuberculosis. 

Classification. — An  exact  classification  of  occupational  diseases  is  diffi- 
cult, as  we  have  as  yet  no  standard  nomenclature  for  this  class  of  diseases, 
nor  do  they  differ  essentially  in  the  majority  of  instances  from  the  pathology 
and  clinical  picture  of  diseased  conditions  in  general.  For  the  present  we  may 
divide  them  into  three  general  classes,  viz: 

(■a)  Specific  occupational  diseases,  which  include  all  diseases  caused  by 
industrial  poisons  or  specific  organisms  which  enter  the  system  in  the  course 
of  employment  and  are  traceable  to  definite  materials  used,  also  diseases  and 
sequelae  caused  by  exposure  to  increased  atmospheric  pressure. 

(b)  Systemic  occupational  diseases  include  all  disorders  caused  by  the 
movements,  position  of  the  body,  overexertion,  dust  and  fumes  and  abnor- 
mal working  conditions,  such  as  excessive  heat,  cold,  moisture,  or  sudden 
changes. 

(c)  Occupational  diseases  of  special  senses  and  organs  include  all  affections 
due  to  exposure  to  defective  or  intense  light,  excessive  heat  and  noises, 
mental  and  physical  strain,  mechanical,  toxic  and  caustic  agents,  etc. 

But  even  a  classification  according  to  causes  is  not  exact,  as  many  of  the 
diseases  contracted  in  industrial  pursuits  are  due  to  a  combination  of  causes 
and  the  so-called  predisposing  factors  play  a  very  important  role.     We  will 
now  briefly  consider  the  most  important  causes  of  occupational  diseases: 
27  417 


41 8         ETIOLOGY    AND    PROPHYLAXIS    OF    OCCUPATIONAL    DISEASES 

Industrial  poisons,  according  to  Dr.  R.  Fischer,  are  to  be  defined,  in 
general,  as  those  raw  materials  and  products,  by-products,  and  waste 
products  which,  in  their  extraction,  manufacture  and  use  in  industrial 
processes  may,  notwithstanding  the  exercise  of  ordinary  precaution,  find 
entrance  into  the  body  in  such  quantities  as  to  endanger,  by  their  chemical 
action,  the  health  of  the  workmen  employed. 

Eulenburg's  Encyclopedia,  published  in  1898,  under  the  heading  "  Arbeit- 
erhygiene"  gave  a  list  of  31  industrial  poisons.  This  list  was  amplified  in 
1908  by  Prof.  Th.  Sommerfeld,  Sir  Thomas  Oliver  and  Prof.  Felix  Putzey, 
and  again  amended  by  Industrial  Inspector  Dr.  R.  Fischer,  in  1910.  Som- 
merfeld's  final  draft  was  referred  to  the  permanent  advisory  council  of  hy- 
giene of  the  International  Association  for  Labor  Legislation,  composed  of 
Dr.  R.  Fischer  of  Berlin,  L.  Teleky  of  Vienna,  J.  P.  Langlois  of  Paris,  Sir 
Thomas  Oliver  of  England,  and  Prof.  Dr.  L.  Devoto  of  Milan,  by  whom  it 
was  edited,  approved  and  finally  pubhshed  by  the  International  Labor 
Oflace  (Basle,  December  24,  191 1).  A  full  translation  of  this  list  was  pub- 
lished by  the  Bureau  of  Labor,  in  Bulletin  100,  May,  191 2.  The  list  deals 
with  54  poisons.  Because  of  its  importance  it  is  reproduced  on  page  720. 
The  advisory  council  of  hygiene  of  the  International  Association  for  Labor 
Protection  also  approved  Fischer's  definition  of  industrial  poisons. 

Acute  and  Chronic  Industrial  Poisoning.- — The  industrial  poisons  may 
enter  the  system  through  the  respiratory  organs,  the  digestive  tract,  through 
the  skin  or  by  a  combination  of  these  channels.  The  effects  are  either  acute 
or  chronic  and  vary  in  severity  from  the  fatal  attacks  of  acute  chlorine  or 
aniline  poisoning  to  the  chronic  intoxications  from  arsenic,  lead,  mercury, 
phosphorus,  etc.  Acute  forms  of  industrial  poisoning  are  fortunately  be- 
coming less  frequent,  but  many  of  the  industrial  poisons  may  produce  both 
acute  and  chronic  effects.  In  the  acute  forms  we  are  dealing  with  profound 
functional  disturbances  caused  by  an  overdose  of  the  various  blood  and  nerve 
poisons;  in  the  chronic  forms,  because  of  diminished  dosage,  the  poisons 
cause  disease  of  a  chronic  character,  by  producing  gradual  histological  changes 
of  the  blood  and  tissues  of  the  body.  There  are  doubtless  numerous  instances 
in  which  minute  quantities  of  poison  are  not  sufficient  to  produce  specific 
effects,  and  yet  bring  about  a  general  deterioration  and  diminished  power  of 
resistance,  as  instanced  by  the  undue  prevalence  of  tuberculosis  among  lead 
and  mercury  workers. 

It  is  well  to  remember  that,  as  in  infectious  diseases  so  in  the  occupational 
intoxications  and  systemic  diseases,  dosage,  individual  susceptibility,  a  low 
state  of  vitahty,  previous  illness,  bronchial  and  gastric  catarrh,  wounds  and 
abrasions  of  the  skin  and  the  alcohol  habit  are  important  predisposing  fac- 
tors. Since  most  of  the  poisons  are  eliminated  by  the  lungs,  liver,  kidneys 
and  skin,*  functional  derangement  of  these  organs  also  plays  an  important 
role. 

The  selective  affinity  of  industrial  poisons  for  certain  organs  or  tissues 


INDUSTRIAL    POISONS 


419 


remains  obscure.  We  can  appreciate  why  lead  should  attack  the  nerves  of 
the  overworked  muscles  of  a  painter's  right  arm  and  cause  paralysis,  com- 
monly called  "wrist-drop,"  or  why  white  phosphorus  should  show  a  special 
affinity  for  a  carious  tooth  and  aid  the  microorganisms  in  their  destructive 
work  in  bringing  about  necrosis  or  the  "phossy  jaw"  of  match  makers.  So 
far,  however,  no  reasonable  explanation  has  been  offered  why  "wood  alcohol" 
should  select  the  optic  nerve,  lead  the  nerve  tissue,  the  tunica  media  of  ar- 
teries, and  arsenic  chiefly  the  nerves  of  the  lower  extremities;  why  hysteria 
or  neurasthenia  should  develop  as  a  result  of  chronic  poisoning  from  three 
such  widely  differing  substances  as  carbon  bisulphide,  manganese  and  mer- 
cury. But  after  all  many  similar  phenomena  are  found  in  diseases  in  general, 
and  the  predilection  of  disease  germs  for  certain  organs  or  tissues  in  particular 
awaits  explanation. 

The  most  important  occupational  intoxications  are  discussed  in  this  work 
by  recognized  experts  and  this  discussion  is  limited  to  a  statement  of  general 
facts. 

Prevalence  of  Industrial  Poisoning. — The  actual  number  of  cases  of  indus- 
trial poisoning  cannot  be  determined  until  there  is  a  uniform  law  requiring 
physicians  to  report  certain  occupational  diseases.  In  countries  like  England, 
where  reports  have  been  compulsory  since  1897,  it  is  quite  possible  to  secure^ 
for  example,  reliable  data  as  to  the  number  of  cases  of  lead  poisoning.  The 
same  may  be  said  of  the  facilities  offered  by  the  statistics  of  the  "  German 
Industrial  Insurance  Institute,"  which  furnish  not  only  the  number  of  deaths 
but  also  the  number  of  cases  treated,  together  with  the  age  period  and  the 
duration  of  the  disease.  Similar  data  should  be  collected  in  all  industrial 
countries.  As  a  matter  of  fact,  prior  to  1910,  in  the  absence  of  statistical 
information  in  this  country  there  was  a  general  impression  that  American 
workmen  were  largely  immune  from  the  dangers  of  industrial  poisons.  The 
publication  of  Dr.  Andrews'  report,  based  upon  a  study  of  15  match  factories, 
disclosed  the  fact  that  65  per  cent,  of  the  employees  were  exposed  to  the 
dangers  of  phosphorus  poisoning,  and  82  cases  of  serious  poisoning  were 
found  in  three  factories  alone.  This  report  and  the  investigations  of  Drs. 
Alice  Hamilton  and  Andrews  on  the  prevalence  of  lead  poisoning  in  the  United 
States,  also  conducted  by  the  Bureau  of  Labor,  together  with  the  facts  col- 
lected by  the  Illinois  Commission  on  Occupational  Diseases,  led  to  a  realiza- 
tion of  the  importance  of  full  and  accurate  knowledge  concerning  the  exist- 
ence of  dangers  from  industrial  poisons  and  their  prevention.  Thanks  largely 
to  the  efforts  of  the  National  Association  for  Labor  Legislation,  Congress,, 
after  two  years'  delay,  by  an  Act  approved  April  9,  191 2,  practically  abol- 
ished the  manufacture  of  poisonous  matches  by  imposing  a  tax  at  the  rate  of 
2  cts.  per  100  matches  upon  all  white  phosphorus  matches  manufactured  in 
the  United  States  after  July  i,  1913. 

In  191 1  six  states,  California,  Connecticut,  Illinois,  Michigan,  New  York, 
and  Wisconsin,  enacted  laws  requiring  physicians  to  report  certain  occupa- 


420        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

tional  diseases  in  their  practice.  In  191 2  Maryland  and  New  Jersey  enacted 
similar  laws,  and  during  1913  Maine,  Massachusetts,  Minnesota,  Missouri, 
New  Hampshire,  Ohio,  and  Pennsylvania  enacted  similar  legislation.  The 
lack  of  uniformity  in  these  laws  is  to  be  regretted.  The  most  comprehensive 
law  was  enacted  in  Missouri.  We  have  as  yet  no  tabulated  returns  from  these 
reports,  and  while  it  is  doubtful  whether  even  one-fourth  of  all  the  cases  will 
be  reported,  the  returns  will  at  least  furnish  more  accurate  knowledge  con- 
cerning the  existence  of  industrial  hazards  from  this  source. 

This  knowledge  will  be  of  great  practical  value  because,  as  a  result  of  pre- 
ventive measures,  factory  sanitation  and  education  of  the  employees,  a 
gratifying  reduction  in  the  morbidity  and  mortality  of  wage  earners  has 
everywhere  taken  place.  For  example,  in  Great  Britain,  where  notification 
was  made  compulsory  in  1897,  the  number  of  cases  of  lead  poisoning  has  been 
reduced  from  1278  in  1898  to  505  in  1910. 

The  economic  importance  of  the  subject  must  be  apparent  from  the  fact 
that  according  to  the  Leipsic  Industrial  Insurance  statistics  of  1910,  1270 
cases  of  lead  poisoning  were  cared  for,  with  an  average  duration  of  36.2  days, 
involving  45,794  days'  loss  of  work.  This  is  all  the  more  lamentable  since 
many  of  these  patients  are  subject  to  relapses.  The  Vienna  statistics 
cited  by  Koelsch^  show  that  of  516  painters,  during  the  course  of  4  years, 
263  suffered  from  one  attack,  85  from  two  attacks,  25  from  three,  i  from  eight 
and  I  from  nine  attacks.  According  to  Kaup's-  statistics  the  morbidity 
rates  among  about  5000  Berlin  painters  between  1905  and  1908  were  20 
per  cent,  above  the  average  in  other  occupations,  the  duration  of  illness  80 
per  cent,  higher,  the  mortality  rates  during  the  productive  age  50  per  cent, 
higher,  and  the  tuberculosis  death  rate  4  per  1000  higher.  The  Leipsic 
statistics  also  reveal  an  undue  prevalence  of  gout  among  the  workers  in  lead 
trades. 

The  number  of  cases  of  mercurial  poisoning  has  also  been  greatly  di- 
minished by  the  employment  of  less  harmful  substances  and  general  precau- 
tionary measures.  For  example,  the  number  of  sick  days  from  mercurialism, 
which  in  1885  among  160  mirror  platers  at  Fiirth  amounted  to  5463  days, 
has  been  wholly  eliminated  by  the  substitution  of  nitrate  of  silver.  The 
number  of  cases  among  the  miners  and  smelters  of  Idria  has  been  reduced  from 
122  in  1896  to  5  in  1908. 

Similar  gratifying  reductions  are  reported  in  phosphorus  poisoning,  and 
with  prohibitive  legislation  it  is  only  a  question  of  time  when  cases  of  necrosis 
of  the  jaw,  which  formerly  afflicted  between  11  and  12  per  cent,  of  match 
makers,  will  entirely  disappear. 

According  to  Bauer, ^  4320  cases  of  poisoning  occurred  in  the  German 
Chemical  Industry  between  1894  and  1904.  From  1900  to  1905  the  number 
of  accidents  was  far  above  the  average  of  66  other  occupations.  In  1907 
there  were  still  371  cases  of  poisoning  in  this  industry,  with  151  deaths.  Of 
170  cases  from  toxic  gases  69  occurred  in  this  industry,  ^2  were  caused  by 


INDUSTRIAL    POISONS  421 

carbon  monoxide,  27  by  furnace  and  illuminating  gases,  16  by  mine,  powder 
and  dynamite  gases,  and  2  by  well  gases.  Fortunately  the  number  of  such 
accidents  is  constantly  diminishing,  especially  in  the  anihne  and  coal-tar 
industry.  In  a  roburite  factory  at  Witten,  with  a  morbidity  rate  of  96  per 
cent,  in  1895,  ^o  cases  of  poisoning  from  dinitrobenzol  have  occurred  since 
1903. 

Importance  of  the  Industrial  Poisons  from  the  Medico-legal  Standpoint. — 
The  question  of  international  protection  of  labor  was  agitated  as  early  as  1870, 
but  it  was  not  until  1890  that  the  first  international  conference  was  held,  in 
Berlin.  This  was  followed  by  an  International  Congress  at  Paris  in  1900 
and  the  establishment  of  an  International  Association  for  Labor  Protection, 
with  a  Bureau  at  Basle,  in  1901.  The  object  of  this  organization  is  to  secure 
the  enactment  of  uniform  labor  laws,  to  collect  and  publish  literature  on  the 
cause  and  prevention  of  industrial  diseases  and  accidents,  and  to  promote 
the  welfare  of  the  laboring  classes  in  general.  It  is  largely  due  to  the  efforts 
of  this  organization  that  the  use  of  white  phosphorus  in  the  manufacture  of 
matches  has  to  a  great  extent  been  prohibited  and  that  so  much  has  been 
accomplished  in  the  prevention  of  lead  poisoning,  by  the  substitution  of 
leadless  processes  in  different  industries.  Indeed  there  are  many  leaders  in 
the  medical  profession,  men  like  Sir  Thomas  Oliver,  Professor  Sommerfeld 
and  others,  who  believe  that  the  interests  of  humanity  demand  the  substitu- 
tion of  white  zinc  for  the  use  of  white  lead  in  paint.  It  is  also  due  to  the 
efforts  of  this  organization  that  men  in  the  front  ranks  of  social  medicine 
prepared  a  list  of  industrial  poisons.  The  care  exercised,  so  that  no  injustice 
may  be  done  to  employees  under  the  liability  acts,  is  shown  by  Dr.  Fischer's 
definition  of  industrial  poison.  The  question  whether  the  benefits  of  the 
workingmen's  compensation  acts,  which  formerly  applied  to  accidents  only, 
should  be  extended  to  cases  of  acute  industrial  poisoning  came  up,  and'^a 
number  of  countries  decided  to  include  certain  of  the  occupational  diseases 
with  industrial  accidents.  The  question  now  uppermost  in  the  minds  of 
thoughtful  men  is  whether  it  is  a  social  justice  to  allow  damages  in  the  case  of 
loss  of  a  limb  by  machinery  accident,  and  to  ignore  the  claims  of  a  workman 
whose  arm  is  disabled  by  lead  paralysis,  and  whether  it  is  fair  that  the  depend- 
ents of  a  wage  earner  who  perishes  from  an  attack  of  acute  industrial  poison- 
ing should  receive  a  pension,  while  those  in  the  case  of  a  worker  who  dies 
from  the  chronic  effects  of  the  same  poison  do  not.  Already  France,  Switzer- 
land, and  England  have  extended  the  original  list  of  notifiable  diseases.  In 
England,  for  example,  the  Act  of  1906  which  originally  covered  only  six  in- 
dustrial diseases  was  extended  in  1907-1908  and  again  in  1913.  It  now  in- 
cludes the  following:^  anthrax,  arsenic,  ankylostomiasis,  lead,  mercury,  phos- 
phorus, nitro  and  amido  derivatives  of  benzene,  denitrobenzol  and  aniline, 
carbon  bisulphide,  nitrous  fumes,  nickel  carbonyl,  African  boxwood,  chrome, 
ulceration,  ulcerations  produced  by  dust  or  caustic  or  corrosive  liquids,  can- 
cer or  ulcerations  of  the  skin  or  of  corneal  surface  of  eye  due  to  pitch,  tar  or 


422         ETIOLOGY    AND    PROPHYLAXIS    OF    OCCUPATIONAL    DISEASES 

tarry  compounds,  chimney-sweeps'  cancer,  glanders,  compressed-air  illness 
or  its  sequelae;  and  the  following  affections  peculiar  to  miners:  nystagmus, 
beat-hand  (subcutaneous  cellulitis)  of  coal  miners,  bent  knee  and  bent  elbow 
and  inflammation  of  the  synovial  lining  of  the  wrist-joint  and  tendon  sheaths 
of  miners;  also  cataract  in  glass  workers,  telegraphist's  cramps,  and  writers' 
cramp.  "In  order  to  claim  compensation  a  workman  must  produce:  (i) 
a  certificate  from  the  local  certifying  factory  surgeon;  (2)  or  prove  that  he  had 
been  suspended  from  his  usual  employment  on  account  of  having  contracted 
one  of  the'  diseases  scheduled;  and  (3)  in  the  event  of  death  proof  will  have 
to  be  given,  by  friends  or  dependents,  that  death  was  due  to  one  of  the  dis- 
eases mentioned  above  (Oliver)."^ 

It  is  not  improbable  that  the  extension  of  the  liability  act  to  dangerous 
occupations  will  involve  more  or  less  litigation  and  possibly  also  lead  to  the 
practice  of  malingering.  There  is  already  more  or  less  literature  on  this  sub- 
ject, and  also  on  the  relation  of  a  traumatic  injury  received  to  the  develop- 
ment of  diseases  which,  sooner  or  later,  incapacitate  the  individual  from  work. 
Considerable  evidence  has  been  accumulated  on  chest  injuries  in  relation  to 
the  development  of  pneumonia  or  to  the  lighting  up  of  a  latent  tuberculous 
lesion  of  the  lung,  on  injuries  of  the  knee  as  an  exciting  cause  of  tuberculous 
inflammation  of  the  knee-joint,  and  on  blows  upon  the  abdomen  as  a  cause  of 
Addison's  disease.  Traumatic  injuries  in  general  are  regarded  as  an  occa- 
sional cause  of  malignant  growth,  and  the  same  is  true  of  habitual  exposure  to 
aniline,  coal  tar,  paraffine,  etc.  Diabetes  insipidus  may  develop  as  a  result 
of  injury  to  the  back  of  the  head,  and  diabetes  mellitus  is  liable  to  be  aggra- 
vated, if  not  induced,  by  severe  physical  and  mental  strain. 

The  German  Industrial  Insurance  system  appears  to  reduce  the  chances 
for  litigation  to  a  minimum  by  securing  perfect  cooperation  between  the 
employer,  the  employees,  technical  experts,  factory  inspectors,  officials  and 
physicians. 

Measures  for  the  Protection  of  Industrial  Workers  against  the  Dangers  of 
Poison;  Compiled  by  Industrial  Councillor  Dr.  Fischer  of  Berlin. 

"i.  Properly  adapted  buildings,  thick  walls  of  separation  for  dangerous 
rooms,  good  lighting,  facilities  for  keeping  the  workshops  clean  and  for 
effective  ventilation. 

2.  Apparatus  adapted  to  its  special  purpose,  whenever  possible,  closing 
tight  in  every  part. 

3.  Appliances  for  accomplishing  the  arrest  of  gases  and  dust  at  their  place 
of  origin,  their  removal  (by  exhaust  fans),  and  in  a  suitable  manner  rendering 
them  innocuous  or  collecting  them,  thus  preventing  their  entrance  in  the  nose 
and  mouth. 

4.  So  far  as  possible,  avoidance  of  direct  contact  with  poisonous  materials 
or  substances  injurious  to  health  in  working  with  them,  transporting  or  pack- 
ing them. 

5.  The  displacement  of  particularly  dangerous  labor  methods  and  mate- 


INDUSTRIAL    POISONS  423 

rials  by  the  introduction  of  less  dangerous  labor  processes  and  material,  as 
well  as  by  the  employment  of  materials  satisfactorily  pure  chemically. 

6.  Instruction  of  workmen,  just  entering  upon  an  occupation,  concerning 
the  properties  of  the  poisonous  substances  extracted,  manufactured,  used  or 
otherwise  evolved,  and,  whenever  possible,  cautionary  leaflets  should  be 
placed  in  the  hands  of  the  workers. 

7.  The  repetition  of  these  instructions  at  frequent  intervals. 

8.  Posting  of  precautionary  regulations  and  warning  placards,  containing 
admonitions  for  the  exercise  of  special  caution,  and  enjoining  the  observance 
of  measures  for  insuring  safety.  Constant  supervision  of  all  dangerous  em- 
ployments by  expert  and  responsible  persons. 

9.  Employment  of  appropriate  means  for  personal  protection  in  the  way  of 
suitable  work  clothes,  caps,  gloves,  goggles,  and,  as  necessary  adjuncts,  mouth 
and  nose  shields,  respiratory  masks  and  the  like,  in  case  the  appliances  named 
in  rule  3  are  inapplicable. 

10.  Practice  of  bodily  cleanliness  by  the  use  of  wash,  bath  and  dressing 
rooms,  the  use  of  special  rooms  for  eating,  separate  lockers  for  street  and 
work  clothes,  and  frequent  non-hazardous  cleaning  of  the  clothing. 

11.  Immediate  report  of  symptoms  of  indisposition,  attention  to  wounds 
of  the  skin  caused  by  the  handling  of  corrosive  materials,  prompt  employ- 
ment of  a  reliable  antidote,  and  summoning  at  the  same  time  of  a  physician. 

12.  The  employment  of  a  healthy  working  force.  Periodical  medical 
examination  of  the  workers  in  dangerous  employments.  Temporary  or 
permanent  exclusion  of  unfit  workmen  from  the  dangerous  departments  of 
the  industry.  Under  certain  circumstances  there  should  be  a  change  of 
work  in  occupations  giving  rise  to  chronic  poisoning. 

13.  The  utmost  possible  reduction  of  the  hours  of  labor  in  dangerous 
employments." 

Many  of  these  excellent  rules  will  be  extended  under  specially  hazardous 
employments.  It  is  needless  to  point  out  that  every  dangerous  industry 
should  be  provided  with  a  "first-aid  outfit."  In  employments  involving 
exposure  to  toxic  gases  or  electricity,  oxygen  apparatus,  pulmotors  and  Melt- 
zer's  resuscitation  apparatus  are  indispensable. 

Rescuing  parties  must  likewise  seek  protection  in  the  way  of  forced  venti- 
lation, breathing  helmets,  etc.  It  is  cheaper,  and  certainly  more  humane, 
for  large  concerns  to  provide  not  only  these  safeguards,  but  also  competent 
medical  service,  than  to  pay  compensation  under  the  liability  act.  But  after 
all  the  chief  aim  and  object  must  be  prevention. 

Industrial  Infectious  Diseases. — In  this  class  of  diseases  the  germs  enter 
the  system  in  the  course  of  employment  and  are  traceable  to  the  materials 
used  or  to  the  soil,  premises  or  environment.  The  most  important  infections, 
such  as  anthrax,  uncinariasis,  tuberculosis,  etc.,  are  dealt  with  in  special 
chapters  and  also  under  different  occupations,  hence  only  a  few  salient  facts 
bearing  on  general  etiology  and  prevention  will  be  presented  here. 


424         ETIOLOGY    AND    PROPHYLAXIS    OF    OCCUPATIONAL    DISEASES 

(c)  Uncinariasis.- — This  infection  is  liable  to  occur  among  all  workers  in 
fecally  polluted  soils,  especially  in  miners,  tunnel  workers,  quarrymen,  brick 
and  pottery  workers,  farmers  and  planters  and  persons  employed  in  lumber 
and  construction  camps.  The  economic  importance  of  hook-worm  infection 
must  be  apparent  when,  according  to  Ashford,^  about  800,000  persons,  or 
90  per  cent,  of  the  laborers  in  the  coffee  and  sugar  plantations  of  Porto  Rico, 
were  infected.  Stiles^  estimates  the  number  of  victims  in  the  United  States 
at  2,000,000,  and  the  economic  loss  from  inability  to  work  at  Sioo, 000,000 
per  annum.  That  this  disease  is  both  preventable  and  curable  is  shown  by 
the  results  achieved  in  Porto  Rico  and  in  certain  mining  districts  of  Europe 
(see  pages  181,  624). 

{b)  Anthrax. — This  occupational  infection,  from  the  standpoint  of  fre- 
quency, is  insignificant  when  compared  with  the  hook-worm  disease.  The 
prevalence  of  anthrax  in  different  occupations  is  well  illustrated  by  the  Ger- 
man statistics  of  19 10,  covering  287  cases  with  39  deaths  and  affecting 
257  males  and  30  females.  According  to  Koelsch,^  in  135  cases  the  infection 
was  traced  to  live  or  dead  animals,  in  142  instances  to  the  offal  of  infected 
animals,  one  case  was  contracted  by  a  laboratory  worker,  and  in  nine  in- 
stances the  source  of  infection  could  not  be  determined.  The  257  male  cases 
were  distributed  as  follows:  Agriculture,  121;  flaying  establishments,  9;  hide 
trades,  8;  tanneries,  92;  leather,  3;  transport  laborers,  7;  horsehair  factories, 
11;  brush  and  hair  factories,  4;  wool  carding,  i;  and  glue  factories,  i. 

{c)  Actinomycosis. — This  disease,  known  as  "lumpy  jaw"  in  cattle,  is 
caused  by  the  ray  fungus,  and  is  generally  believed  to  be  transmitted  from 
animal  to  man.  Since  the  natural  habitat  of  the  fungus  is  on  grass  and  grain 
straw,  it  may  possibly  be  conveyed  by  placing  grass  or  grain  straw  in  the 
mouth.  The  majority  of  cases  occur  among  farmers  and  stockmen.  At  all 
events,  of  the  27  cases  studied  by  Rigler  at  the  clinic  of  Jena,  18  affected 
farmers.  The  disease  is  characterized  by  chronic,  generally  localized,  sup- 
purative conditions,  accompanied  by  destructive  processes  of  the  tissues, 
and  if  the  seat  of  the  lesion  affects  some  internal  organ  the  termination  is 
usually  fatal. 

{d)  Foot  and  Month  Disease. — This  affection  primarily  affects  cattle 
sheep,  goats,  and  pigs  and  is  communicable  to  man.  The  disease,  also  known 
as  "aphthous  fever,"  is  occasionally  observed  in  persons  connected  with  the 
animal  industries.  After  an  incubation  of  from  4  to  5  days  the  disease  is 
ushered  in  by  a  chill,  followed  by  fever  and  the  formation  of  vesicles  upon  the 
tongue,  lips  and  mucous  membrane  of  the  buccal  cavity  and  pharynx. 
The  vesicles  soon  break  and  leave  painful  ulcers.  Occasionally  also  miliary 
and  pustular  eruptions  are  observed  on  the  hands. 

(e)  Glanders  and  Farcy. — This  disease  affects  primarily  the  horse,  ass, 
or  mule  and  may  be  transmitted  to  man  through  wounds  and  abrasions,  by 
direct  contact  with  the  mucopurulent  secretions,  by  droplet  infection,  by 
the  inhalation  of  dried  and  pulverized  discharges,  or  through  the  medium  of 


INDUSTRIAL    INFECTIOUS    DISEASES  425 

horse  blankets,  harness,  stable  utensils,  etc.  The  disease  is  also  communicable 
from  man  to  man.  It  is  known  as  glanders  when  it  attacks  the  mucous 
membranes  and  as  farcy  when  it  affects  the  skin.  In  either  case  the  course 
may  be  acute  or  chronic  and  may  vary  in  severity  from  a  slight  local  infection 
to  a  profound  general  pyaemic  condition.  The  prognosis  is  extremely  un- 
favorable, as  from  50-80  per  cent,  of  the  cases  terminate  fatally.  Bollinger, 
cited  by  Koelsch,  has  collected  106  cases;  of  these,  66  occurred  in  hostlers 
and  coachmen;  10  in  veterinarians;  6  in  horse  butchers  and  6  in  persons  em- 
ployed in  flaying  dead  animals;  5  in  soldiers;  4  in  physicians;  2  in  horse 
dealers;  i  in  a  horseshoer;  i  in  an  anatomical  laboratory  worker;  and  5  in 
other  occupations. 

(/)  Septic  infections  are  not  infrequently  observed,  especially  among 
persons  engaged  in  the  flaying  of  dead  animals,  the  manufacture  of  artificial 
manure,  glue  and  tallow  factories,  the  hide,  tanning  and  rag  industr\^,  in 
renovating  hair  mattresses  and  feathers,  in  silk  workers,  cannery  employees, 
butchers,  game  dealers,  cooks,  physicians,  veterinarians,  laboratory  men, 
workers  in  aniline,  grease,  paraffine,  etc.  The  streptococci  and  staphylococci 
may  enter  the  system  through  wounds  and  abrasions,  through  the  medium 
of  biting  flies  or  insects,  or  through  the  sebaceous  follicles,  or  they  may  be 
inhaled.  The  infection  may  manifest  itself  by  localized  affections,  such  as 
furuncles,  or  by  the  graver  forms  of  cellulitis,  lymphangitis,  erysipelas, 
septic  sore  throat  and  joint  infections,  and  even  by  profound  general 
septicaemia. 

(g)  Smallpox  and  cowpox  are  occasionally  contracted  by  persons  engaged 
in  handling  infected  clothing,  laundry,  bedding,  rags,  feathers,  etc.  The 
danger  of  handling  fresh  feathers  and  raw  cotton  imported  from  countries 
where  smallpox  is  endemic  has  recently  been  emphasized  by  Shablowsky^ 
and  by  Corbin.^  The  disease  may  also  be  contracted  by  nurses  and  at- 
tendants, and  by  employees  of  hotels,  inns,  etc.,  especially  by  chamber- 
maids. I  recall  two  small  epidemics  in  which  the  infection  was  evidently 
carried  all  the  way  from  Chicago  by  a  traveller  who,  although  apparently 
well  himself,  left  foci  of  infection  in  two  hotels. 

Cowpox  is  occasionally  contracted  by  farmers  and  dairymen,  especially 
during  the  act  of  milking. 

(//)  Syphilis. — The  virus  of  the  disease  caused  by  the  "spirocheta  pallida" 
evidently  clings  to  the  secretions  of  syphilitic  ulcers  and  may  be  convej'ed  in 
an  extragenital  way  by  kisses,  wet  nursing,  use  of  infected  pipes,  cigars  and 
cigarettes,  by  the  promiscuous  use  of  glass-blower's  pipes  and  the  mouth- 
pieces of  wind  instruments,  by  dental  and  surgical  instruments,  and  during 
digital  examination  by  physicians  and  midwives,  in  case  of  abraded  surfaces, 
hangnails,  etc.  Scheuer,^"  who  collected  297  cases  of  occupational  syphilis, 
mostly  among  physicians,  midwives  and  nurses,  also  reports  a  series  of  cases 
in  paper-hangers,  cabinetmakers,  shoemakers,  saddlers,  painters,  dress- 
makers, who  were  infected  by  putting  in  the  mouth  or  between  the  lips  such 


426         ETIOLOGY    AND    PROPHYLAXIS    OF    OCCUPATIONAL    DISEASES 

things  as  pencils,  nails,  awls,  needles,  wire,  thread  and  brushes,  previously 
infected  by  syphilitic  fellow-workers.  According  to  the  same  author,  clerks, 
accountants,  and  waiters  have  contracted  the  disease  by  holding  infected 
lead  pencils,  pen  holders,  and  even  coins  between  their  lips;  he  also  re- 
ports instances  of  transmission  in  persons  employed  in  the  laundry  and  rag 
industries. 

(i)  Tetanus  is  a  typical  soil  disease  and  infections  have  been  reported 
as  incident  to  occupation,  not  only  in  workers  of  the  soil  but  also  in  the  jute 
industry. 

{k)  Tuberculosis. — This  disease,  on  account  of  its  importance,  is  discussed 
in  a  separate  paper.  It  is  not  a  specific  occupational  disease,  except  perhaps 
in  some  instances  where  the  infection  is  conveyed  in  autopsy  work,  or  in  the 
transmission  of  bovine  tuberculosis,  as  in  the  case  of  butchers,  cooks  and 
dairy  employees,  who  have  contracted  tuberculosis  of  the  skin  by  handling 
infected  meat,  milk  and  cream. 

The  writer, ^^  in  1903,  collected  12  cases  of  tuberculous  wound  infection 
in  veterinarians  and  butchers,  and  three  cases  of  accidental  inoculation  in 
man  by  the  topical  application  of  cream  and  milk.  Lassar^^  reports  11  cases 
of  verrucose  tuberculosis  in  butchers  and  abattoir  employees  from  wound 
inoculations.  It  is  also  conceivable  that  the  disease  is  occasionally  conveyed 
by  infected  clothing  and  foot  wear;  at  all  events  Perlen^^  informs  us  that  of 
4177  tuberculous  subjects  treated  in  the  Munich  clinic  709  were  engaged  in 
repair  and  cleaning  shops  of  foot  wear  and  clothing. 

There  is  abundant  statistical  evidence,  both  here  and  abroad,  that  persons 
engaged  in  the  mechanical  and  manufacturing  industries  pay  a  terrific  toll 
to  the  so-called  ''white  plague."  Our  latest  census  statistics,  from  the  regis- 
tration area  in  the  United  States,  show  that  the  industrial  classes,  which 
constitute  about  one-third  of  the  population,  contribute  almost  one-hal!  of 
all  the  deaths  from  tuberculosis.  It  is  now  generally  held  that  in  nearly 
90  per  cent,  of  the  poorer  classes,  tuberculosis  is  contracted  in  childhood  and 
the  germs  remain  dormant  until  adverse  conditions  create  a  favorable  soil 
for  their  growth  and  development.  Such  a  soil  is  usually  found  in  persons 
whose  body  has  been  weakened  from  any  of  the  numerous  causes  which 
exist,  whether  it  be  a  previous  attack  of  sickness,  malnutrition,  loss  of  sleep, 
vice  and  dissipation  or  other  debilitating  factors. 

In  view  of  the  fact  that,  as  a  general  rule,  only  able-bodied  persons  enter 
the  ranks  of  industrial  workers,  the  question  naturally  arises,  why  should 
such  a  large  percentage  of  strong  men  and  women  fall  victims  to  the  disease? 
This  is  not  at  all  strange  when  we  consider  the  many  unfavorable  factors  to 
which  they  are  subjected,  such  as  crowded  and  insanitary  workshops,  long 
hours  in  a  bad  air,  overwork  and  fatigue,  deficient  light,  dampness,  exposure 
to  extremes  of  heat  and  cold,  sudden  changes  in  temperature,  and  last  but 
not  least  the  inhalation  of  dust,  toxic  fumes,  etc.  All  of  these  factors 
are   calculated   to   lower   the  power  of  resistance  and  favor  not  only  the 


INDUSTRIAL    TUBERCULOSIS  427 

development  but  also  the  spread  of  the  disease,  especially  when  some  of 
the  workmen  are  already  afflicted  and  are  careless  in  the  disposition  of  their 
expectoration. 

The  influence  of  occupation  is  strikingly  shown  by  the  fact  that  the  tuber- 
culosis rate  among  472,000  males  in  the  United  States,  exposed  in  15  occu- 
pations to  the  inhalation  of  organic  dust,  was  2.29  per  1000,  against  a  rate  of 
1.55  for  all  occupied  males;  and  also  by  the  fact  that  42.05  per  cent,  of  the 
deaths  of  printers,  lithographers  and  pressmen,  who  died  at  the  ages  between 
25  and  44  years,  were  from  consumption,  as  compared  with  21.85  P^^  cent, 
for  farmers,  planters  and  overseers.  Similar  data  collected  by  Koelsch  in 
Bavaria,  Elben  in  Wiirtenberg  and  the  Registrar  General  of  Great  Britain 
could  be  adduced  to  emphasize  this  point.  Suffice  it  to  state  that  the 
German  Industrial  Insurance  statistics  show  that  while  only  77  agricul- 
turists per  1000  are  invalided  by  consumption,  the  rate  among  industrial 
workers  is  245. 

Hirt  was  one  of  the  first  to  show  that  persons  employed  in  dust-pro- 
ducing occupations  suffer  much  more  frequently  from  pneumonia  and  con- 
sumption than  those  not  exposed  to  dust  and  that  there  is  practically  no 
difference  in  frequency  of  disease  of  the  digestive  organs. 

Con-  Ti  Digestive 

,     sumption     i  P^^^^°^'^  ;  disorders 


7-4 

17.8 

5-9 

16.6 

6.0 

152 

7-7 

20.  2 

9-4 

157 

4.6 

16.0 

Workers  in  metallic  dust 28 .  o 

Workers  in  mineral  dust 25 .  2 

Workers  in  mixed  dust 22.6 

Workers  in  animal  dust 20 . 8 

Workers  in  vegetable  dust 13.3 

Workers  in  non-dusty  trades 11.  i 

Perlen^^  analyzed  the  histories  of  1426  tuberculous  patients  with  refer- 
ence to  dust  exposure  and  found  that  30  per  cent,  had  been  exposed  to  metallic 
dust,  26  per  cent,  to  vegetable  dust,  18  per  cent,  to  mineral  dust,  17  per  cent. 
to  mixed  dust,  and  8  per  cent,  to  animal  dust. 

Sommerfeld's  statistics  show  that,  with  an  average  tuberculosis  death 
rate  of  4.93  per  1000  of  the  population  in  Berlin,  the  rate  in  non-dusty  trades 
was  2.39  and  in  dusty  trades  5.42.  In  trades  giving  rise  to  metallic  dust, 
5.84;  in  copper,  5.31;  iron,  5.55;  lecui,  7.79.  In  trades  giving  rise  to  mineral 
dusts,  pottery  workers,  14;  masons,  4.26;  stone  cutters,  34.9.  Organic  dusts, 
leather,  furs  and  feathers,  4.45;  wool  and  cotton,  5.35;  wood  and  paper,  5.96; 
tobacco  dust,  8.47.^ 

The  amount  of  dust  is  perhaps  less  important  than  the  character  and 

chemical  composition  of  the  particles  composing  it.     For  this  reason,  no 

doubt,  the  hard,  sharp,  and  angular  particles  of  iron,  steel,  and  mineral 

1  See  pages  484,  504,  520,  579,  585,  608,  617,  642,  656,  659.  665,  669.  678,  683,  701,  777. 


428         ETIOLOGY    AND    PROPHYLAXIS    OF    OCCUPATIONAL    DISEASES 

dust  are  more  liable  to  produce  injuries  of  the  respiratory  passages,  thus 
favoring  the  invasion  of  bacilli  or  lighting  up  latent  lesions.  On  the  other 
hand,  it  will  be  shown  in  subsequent  pages  that  exposure  to  certain  kinds 
of  dust,  such  as  coal,  lime,  gypsum,  sulphur  and  tan  bark,  may  have  an  in- 
hibitory effect  on  the  disease. 

It  would  be  unfair  not  to  consider  the  influence  of  home  environments 
such  as  unclean,  crowded  or  otherwise  insanitary  dwellings,  insufficient  or 
improper  food,  ignorance  or  disregard  of  correct  living  and  working  condi- 
tions, and,  last  but  not  least,  the  bad  efTects  of  the  abuse  of  alcohol.  It 
has  been  shown  that  the  abuse  of  alcohol  not  only  lowers  the  general  resist- 
ance of  the  body,  but  the  habit  of  visiting  and  remaining  in  saloons  for  hours, 
sometimes  till  midnight,  deprives  the  individual  of  proper  rest  and  exposes 
him  to  devitalized  air  and  the  toxic  fumes  of  tobacco,  carbon  monoxide  and 
dioxide  gases,  and  other  injurious  agents.  The  influence  of  alcohol  is  well 
demonstrated  by  Guttstadt's  statistics.  He  found  that  the  average  death 
rate  from  tuberculosis  in  Prussia  was  16. i  per  cent,  of  all  the  deaths,  the  rate 
in  the  liquor  trades  was  22.3  and  among  bartenders  and  waiters  as  high  as 
52.6  per  cent.  But  as  pointed  out  by  Koelsch  the  question  of  physique 
plays  an  important  role,  since  the  rates  among  the  robust  brewers  and  malt 
workers  of  Bavaria,  in  spite  of  their  intemperate  habits,  is  only  3.25  and  3.56 
respectively.  Vice  and  dissipation  is  not  confined  to  wage  earners  and  the 
startling  facts  remain  that,  even  with  due  consideration  of  all  the  contribu- 
tory causes  referred  to,  the  rates  from  industrial  tuberculosis  are  excessive. 
Indeed  it  has  been  estimated  that  over  70,000  wage  earners  perish  every  year 
from  this  disease  in  this  country. 

Preventive  Measures. — It  is  perfectly  safe  to  state  that,  by  effective 
methods  for  the  prevention  and  removal  of  dust,  fully  one-half  of  these 
lives  could  be  saved. 

This  is  not  at  all  speculative,  since  Prof.  Ropke  informs  us  that,  as  a  re- 
sult of  general  education  and  factory  sanitation,  including  of  course  cuspi- 
dors and  the  prevention  of  promiscuous  expectoration,  the  mortality  at 
Solingen,  in  Germany,  the  population  of  which  is  largely  made  up  of  em- 
ployees in  the  cutlery  industry,  has  been  reduced  from  20.63  P^r  1000  in 
1885  to  9.3  per  1000  in  1910,  and  the  consumption  death  rate  from  540  in  1885 
to  180  per  100,000  of  population  in  1910.  Similar  data  are  available  to  show 
that  diseases  of  the  respiratory  organs  in  one  of  the  German  cement  works 
have  been  reduced  from  9.3  per  cent,  to  7,.t^  per  cent.,  after  the  installation 
of  a  suitable  apparatus  for  the  removal  of  dust. 

What  can  be  done  in  some  of  the  most  dangerous  industries  in  Germany 
can  be  done  in  this  country,  and  will  be  done  as  soon  as  the  importance  of 
the  subject  is  fully  appreciated. 

Ropke's  table,  comparing  Solingen  with  Sheffield,  which  is  the  seat  of 
the  cutlery  industry  in  England,  is  reproduced  for  the  lesson  it  conveys. 


INDUSTRIAL    INFECTIOUS    DISEASES 
Mortality  Statistics 


429 


Solingen  Industrial  Insurance 
Statistics  1909-1910* 

Sheffield  Med.  Officer  of  Health, 
I90i-I909t 

Total 

mortality 

per 

1000 

Mortality 
from 
tuber- 
culosis 

Other  dis- 
eases of  the 
respiratory 
organs 

Total 

mortality 

per 

1000 

Mortality 
from 
tuber- 
culosis 

Other  dis- 
eases of  the 
respiratory 
organs 

Grinders,  polishers,  buffers, 
etc 

9-3° 

4-37 

2-35 

30.40 

15.10 

S-40 

Other    employees    in    the 
steel  and  cutlery  indus- 
try  

9.00 

2.66 

1.79 

■ 
29.30 

5.80 

6.90 

The  marked  contrast  between  these  two  cutlery  centers  was  commented 
upon  by  Mr.  C.  Johnston,  in  the  Annual  Report  of  the  Chief  Inspector  of 
Factories,  as  early  as  1906.  We  quote  from  this  report  as  cited  by  Olivei 
as  follows:  "The  atmosphere  of  Solingen  is  bright  and  clear.  It  is  seldom 
that  black  smoke  is  seen  escaping  from  the  factory  chimney.  This  is  largely 
the  result  of  careful  firing  and  the  use  of  coal  briquettes,  instead  of  ordinary 
coal.  The  factories  are  said  to  be  marvels  of  order  and  cleanliness;  the  floors 
are  of  concrete,  and  the  air  space  for  each  worker  is  565  cu.  ft.  All  the 
grinding  stones  are  protected  by  guards.  The  walls  of  the  work  rooms  are 
lime  washed  every  year;  the  floors  are  swept  clean  every  evening  and  damp 
wiped  once  a  week.  The  'racing'  of  grindstones  is  never  undertaken 
during  the  working  hours,  except  under  a  stream  of  water,  or  unless  the 
stone  is  entirely  inclosed  in  casing,  except  at  the  working  place  of  the  raising 
tool.  One  of  the  features  of  Solingen  is  said  to  be  the  large  number  of 
'home  workers.'  These  workmen  own  their  own  houses,  behind  which  is 
a  garden  and  at  the  rear  of  this  is  their  small  factory.  There  are  1475 
small  factories  of  this  type  in  the  district.  In  these  the  greater  part  of  the 
grinding  and  glazing  of  scissors  and  razors  is  done.  The  floors  are  kept  clean 
and  provisions  are  made  for  the  removal  of  dust  during  the  grinding.  Cutlery 
manufacture  is  recognized  as  a  dangerous  trade  in  Solingen,  and  in  recent 
years  considerable  improvement  has  taken  place  in  the  means  to  prevent 
dust.  With  the  clean  and  tidy  appearance  of  these  tenement  factories  those 
of  Sheffield  compare  most  unfavorably.  In  Solingen  the  grindstones  and 
polishing  wheels  are  run  toward  the  worker;  in  Sheffield  they  are  run  away 
from  the  worker  so  that  the  dust  has  an  upward  tendency  and  ffies  into  the 
room." 

(/)  Parasites. — Among  the  parasites  transmissible  from  animals  to 
man  should  be  mentioned  cysticerci  or  the  larval  form  of   the   tapeworm, 

*  Based  upon  the  statistics  of  7908  grindeis  and  10,872  other  employees  in   the  metal 
industry. 

t  Based  upon  3941  grinders  and  3889  other  metal  workers. 


430        ETIOLOGY    AND    PROPHYLAXIS    OF    OCCUPATIONAL    DISEASES 

and  infection  with  trichina  spiraHs,  which  is  occasionally  acquired  by  butchers, 
sausage  makers,  fishermen  and  cooks,  mostly  as  a  result  of  the  habit  of  eating 
raw  beef,  pork  or  fish. 

Scabies  and  pediculosis  are  not  infrequently  contracted  in  lumber  camps. 
Bedbugs  and  fleas  are  also  great  pests  in  unclean  camps.  The  body  louse 
may  transmit  the  virus  of  typhus  fever.  The  pedicidoides  ventricosis,  de- 
scribed by  Schamberg  and  Goldberger,  occurs  primarily  in  wheat;  it  persists 
in  the  straw  for  months  and  may  possibly  survive  in  flour.  The  eruption 
caused  by  this  parasite  resembles  either  a  severe  form  of  urticaria  or  erythema 
multiforme.  It  is  liable  to  affect  farm  hands,  harvesters,  packers  of  the 
straw  and  all  who  may  later  come  into  contact  with  the  straw,  and  possibly 
those  who  handle  the  flour  (Hazen).  Among  other  mites  capable  of  setting 
up  troublesome  forms  of  dermatitis  are  the  mower  mite,  harvest  bug,  and 
chicken  lice,  which  chiefly  affect  farmers,  gardeners,  poultry  raisers  and 
feather  workers. 

The  barbed  hairs  of  the  brown-tailed  moth,  and  of  its  cocoon  and  cater- 
pillar contain  an  irritant  poison,  which  not  infrequently  causes  a  dermatitis, 
resembling  urticaria,  in  persons  engaged  in  the  eradication  of  the  pest. 

Lumbermen,  rivermen,  guides  and  other  field  workers  frequently  suffer, 
not  only  from  the  local  effects  of  mosquitoe  bites,  but  also  from  systemic 
infections  such  as  malaria,  yellow  fever,  etc.  They  are  not  infrequently 
exposed  to  the  bites  of  moose  and  deer  flies,  sand  flies  or  chiggers,  etc. 

Injurious  Environments. — There  is  abundant  evidence  to  show  that 
the  baneful  effects  attributed  to  occupations  are  in  large  part  caused  by 
faulty  environments  and  working  conditions  and  hence  to  a  great  extent 
avoidable. 

Indoor  Occupations  and  Bad  Air. — It  is  generally  held  that  indoor  em- 
ployment is  inimical  to  health,  while  out- door  work  in  a  pure  air  favors 
health  and  longevity.  This  statement  appears  justified  in  the  light  of 
statistics  furnished  by  Korosi,  who  found  that  out  of  looo  deaths  436  occurred 
in  persons  engaged  in  indoor  occupations  against  322  employed  in  out-door 
work.  The  rate  in  England  (with  a  standard  of  100)  was  55  for  fishermen, 
61  for  gardners,  62  for  agriculturists,  against  84  for  grocers,  152  for  cloth 
dealers,  144  for  tailors  and  233  for  printers.  The  latest  U.  S.  statistics  show 
that  the  mortality  from  tuberculosis  was  16.  i  per  cent,  in  agricultural  pur- 
suits and  23.1  per  cent,  among  bookkeepers  and  accountants,  23.7  per  cent, 
in  tailors  and  28.2  in  printers,  lithographers  and  pressmen.  If  we  stop  right 
here  in  the  comparison  the  evidence  would  be  overwhelming  in  favor  of  out- 
door employment.  But  when  we  find  that  the  mortality  from  consumption 
among  merchants  and  dealers  (except  wholesale)  is  only  16. i  per  cent., 
exactly  the  same  as  in  agriculturists,  and  for  draymen,  hackmen,  and  team- 
sters it  is  23.3  per  cent.,  almost  the  same  as  for  bookkeepers,  it  becomes  ap- 
parent that  in  estimating  the  hazards  of  indoor  occupations  other  factors, 
such  as  physique,  habits,  exposure  to  dust,  social  conditions,  standard  of 


INJURIOUS    ENVIRONMENTS,   VITIATED    AIR  43 1 

living,  etc.,  must  be  considered.  One  of  the  chief  dangers  of  indoor  life  is 
exposure  to  vitiated  air.  The  air  of  dwellings  and  workshops  is  never  as 
pure  as  the  outer  air,  because  it  is  polluted  by  the  products  of  respiration 
combustion  and  decomposition.  The  presence  of  individuals  also  tends  to 
vitiate  the  air  with  dust,  germs  and  organic  matter,  from  the  skin,  mouth, 
lungs  and  soiled  clothing.  Unless  provision  is  made  for  the  dispersion  of 
foul  air,  and  the  introduction  of  pure  air  there  is  much  reason  for  assuming 
that  these  impurities  play  a  more  or  less  important  role  in  what  has  been 
designated  as  "crowd  poisoning,"  characterized  in  the  acute  form  by  symp- 
toms of  oppression,  headache,  dizziness,  and  faintness,  while  the  chronic 
effects  of  deficient  oxygenation  and  purification  of  the  blood  are  plainly 
evinced  by  pallor,  anaemia  impaired  appetite,  and  gradual  loss  of  physical 
and  mental  vigor.  All  of  these  effects  are  intensified  by  exposure  to  excessive 
temperature  and  moisture,  especially  when  hurhan  beings  are  obliged  to 
occupy  a  space  with  an  air  supply  insufficient  for  the  proper  oxygenation  of 
the  blood.  As  a  result  of  habitual  exposure  to  vitiated  air  we  note  an  undue 
prevalence  of  consumption  and  pneumonia  in  crowded  workshops,  dwellings, 
prisons,  public  institutions,  and  formerly  also  in  military  barracks  and  battle- 
ships. Overcrowding  naturally  favors  contact  and  droplet  infections  from 
tuberculosis,  pneumonia,  influenza,  septic  sore- throat,  etc.  The  influence 
of  overcrowding  on  diseases  of  the  air  passages,  amounting  at  times  to  epi- 
demics, was  well  illustrated  on  the  Isthmus  of  Panama  and,  as  suggested  by 
General  Gorgas,^*  accounts  probably  for  the  undue  prevalence  of  these  dis- 
eases among  the  gold  miners  of  the  Transvaal.  By  scattering  the  laborers 
on  the  Isthmus  from  large  and  crowded  barracks  into  single  huts  and  small 
rooms,  with  not  less  than  50  ft.  of  floor  space,  the  pneumonia  rate  was  reduced 
in  a  single  year  from  18.4  per  1000  to  2  per  1000,  and  in  urging  a  similar 
procedure  for  the  Rand  he  predicts  a  like  reduction.  Another  bad  effect 
of  indoor  occupations  is  that  the  work  is  usually  performed  in  a  sedentary 
and  stooped  position,  which,  apart  from  interfering  in  youthful  workers 
with  the  full  development  of  the  chest,  limits  expansion  of  the  lungs  and  also 
causes  constipation,  congestion  of  the  portal  circulation  and  hemorrhoids. 

The  baneful  effects  of  vitiated  air  are  of  course  intensified  when  the 
occupation  is  attended  with  the  production  of  dust  and  fumes,  the  foes  of 
industrial  life. 

Cubic  Air-space  and  Amount  of  Fresh  Air  per  Hour. — It  is  evident  that  the 
question  of  cubic  air-space  for  each  worker  plays  an  important  role  and  for 
the  following  reason:  It  is  known  that  carbon  dioxide  is  not  itself  a  toxic 
agent,  but  an  excess  of  this  gas  in  the  air  of  rooms  leads  to  a  deficiency  of 
oxygen,  and  also  to  defective  elimination  of  CO2  from  the  system,  which  can- 
not be  eliminated,  whenever  the  tension  of  CO2  in  the  air  exceeds  that  of  the 
carbon  dioxide  in  the  blood.  In  order  that  the  respiratory  impurities  may 
not  exceed  certain  limits  (6  volumes  of  carbon  dioxide  per  10,000)  it  has  been 
found  that  an  average  adult  requires  3000  cu.  ft.  of  fresh  air  per  hour,  and 


432        ETIOLOGY   AND   PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

this  amount  should  be  supplied  without  discomfort  to  the  occupant.  Experi- 
ence has  shown  that  the  air  of  a  room  cannot  be  changed  oftener  than  three 
times  in  i  hour  in  winter  without  causing  a  disagreeable  draft,  hence  every 
occupant  should  have  cubic  air-space  of  looo  ft.  This  is  the  ideal  standard, 
and  one  of  the  factory  laws  of  New  York  (1906),  relating  to  certain  manufac- 
tures in  tenements,  provides  that  the  whole  number  of  persons  therein  shall 
not  exceed  one  to  each  1000  cu.  ft.  of  air-space.  Such  an  ideal  standard  is 
not  always  obtainable  in  workshops  and  it  is  believed  that  for  practical  pur- 
poses, an  air-space  of  500-600  cu.  ft.  per  capita  will  suffice,  provided  the  air  is 
renewed  sufficiently  often. 

A  number  of  states  require  an  air-space  of  250  cu.  ft.  for  each  employee, 
between  the  hours  of  6  A.M.  and  6  P.M.,  and,  unless  by  written  consent  of 
the  factory  inspector,  not  less  than  400  cu.  ft.  between  the  hours  of  6  P.M. 
and  6  A.M.,  provided  each  room  is  lighted  by  electricity.  This  is  a 
step  in  the  right  direction,  but  it  would  be  extremely  desirable  to  place 
the  minimum  amount  of  cubic  air-space  at  500  ft.  for  day  work  and  600  ft. 
for  night  work,  unless  electric  lights  are  used,  in  which  case  a  uniform 
standard  of  500  ft.  might  be  prescribed.  At  all  events  the  question  of 
sufficiency  ought  not  to  be  left  to  factory  inspectors.  Either  the  cubic  air- 
space should  be  specified,  or  what  is  equally  effective  the  carbon  dioxide 
contents  of  the  air  should  be  limited  to  12  volumes  per  10,000.  The 
authorities  of  Great  Britain  have  made  a  beginning  in  the  latter  direction  by 
placing  the  limit  of  CO2  at  20  volumes  when  gas  or  oil  is  used  for  lighting 
(or  within  i  hour  thereafter)  and  12  volumes  when  electric  light  is  used  (or 
within  I  hour  thereafter)  and  9  volumes  per  10,000  at  any  other  time. 

Ventilation,  which  means  the  removal  and  dispersion  of  bad  air  and  the 
introduction  of  fresh  air,  is  accomplished  either  by  natural  or  artificial  means. 
Natural  ventilation  is  usually  sufficient  when  each  occupant  has  1000  ft.  of 
cubic  air  space;  the  walls  of  the  building  are  porous  or  contain  numerous  crev- 
ices near  the  doors  and  windows,  the  difference  between  the  indoor  and  out- 
door temperature  is  considerable,  and  the  winds  strike  the  walls  directly  or 
pass  with  great  velocity  over  chimney  flues  and  other  openings.  But  as  the 
direction  and  force  of  the  winds,  and  the  other  factors  referred  to,  cannot  be 
controlled,  other  means  should  be  provided  for  ventilation.  For  this  purpose 
open  windows,  doors,  and  revolving  fans  answer  very  well  in  summer.  The 
objection  to  this  method  is  the  cold  drafts  in  winter.  In  rooms  heated  with 
direct  radiation  the  fresh  air  should  therefore  be  admitted  above  the  heads  of 
the  occupants,  either  by  fresh  air  register  inlets  in  the  walls  or  by  the  inser- 
tion of  louvered  or  swinging  windows.  Thus  an  upward  direction  is  given  to 
the  air,  so  that  it  may  impinge,  on  the  ceiling,  mix  with  and  be  warmed  by  the 
heated  air  in  this  situation,  falling  gently  into  all  parts  of  the  room,  being 
gradually  removed  by  means  of  foul  air  outlets,  aided  by  exhaust  fans. 
Another  simple  plan  is  to  bore  slanting  holes  in  the  bottom  rail  of  the 
window  sash,  or  to  employ  a  Pullman  or  Bury  ventilator,  or  to  insert  a 


VEXTILATIOX,    TEMPERATURE    AND    HUMTDITY  433 

piece  of  board  4  in.  wide  across  the  window  sill.     The  separation  of  the 
sashes  thus  caused  will  provide  for  indirect  fresh-air  inlets. 

Artificial  ventilation,  may  be  secured  by  providing:  (i)  suitable  inlets 
and  outlets;  (2)  by  extraction  by  heat,  or  the  creation  of  a  decided  difference 
between  the  inner  and  outer  temperature;  and  (3)  by  propulsion  and  aspira- 
tion. Space  will  not  permit  to  enter  into  details  except  to  say  that,  besides 
the  contrivances  already  mentioned,  any  of  the  ordinary  registers  in  which  the 
air  passes  through  the  wails  by  means  of  a  perforated  iron  plate,  and  is  then 
directed  upward  by  a  valved  plate  with  side  checks,  will  prove  of  service. 
McKinnell's  ventilator  consists  of  two  cylinders,  one  inside  the  other  and  of 
different  lengths;  the  longer  tube,  projecting  above  and  below,  serves  to 
conduct  the  impure  air,  while  the  outer  cyUnder,  having  a  larger  sectional 
area,  serves  as  an  inlet.  The  outlet  is  protected  on  the  top  by  a  cowl,  and 
both  tubes  can  be  regulated  by  valves.  They  are  especially  useful  in  the 
ventilation  of  one  story  buildings,  or  the  upper  story  of  any  building.  If  gas 
is  used  as  an  illuminant,  the  burners  may  be  placed  immediately  under  the 
extracting  tube.  As  the  warm  air  escapes  through  the  inner  tube  a  corre- 
sponding volume  is  admitted  through  the  interspace  between  the  two  cylinders. 

Ridge  ventilators  consist  of  openings  through  the  ceiHngs  and  roof,  with 
louvered  sides  and  ends,  protected  by  a  small  roof.  The  opening  of  the  air 
shaft  in  the  ceiling  is  usually  provided  with  suitable  registers.  The  fresh  air 
is  admitted  by  the  means  already  referred  to,  or  by  registers  placed  behind 
radiators.  If  the  building  is  heated  by  stoves,  the  fresh  air  may  be  admitted 
by  inlets  running  underneath  the  floor,  between  the  joists,  and  discharging 
through  a  register  near  the  stove. 

Extraction  of  foul  air  by  heat  is  usually  accomplished  by  placing  a  separate 
flue  next  to  the  chimney  flue.  The  latter,  if  in  use  for  firing  purposes,  creates 
an  upward  current.  If  this  is  not  sufficient  it  may  be  promoted  by  gas  jets 
or  a  steam  coil  placed  in  a  separate  flue. 

The  propulsion  and  aspiration  system  is  especially  adapted  for  all  large 
buildings  and  factories,  and  consists  of  mechanical  devices  by  which  the  fresh 
air  is  forced  into  and  distributed  throughout  the  building  by  the  use  of  fans 
or  air  propellers.  The  foul  or  objectionable  air  is  removed  by  so-called  ex- 
haust fans,  preferably  placed  near  the  floor. 

Temperature  and  Humidity.— It  is  a  well-known  fact  that  the  welfare 
and  capacity  for  work  of  individuals  are  to  a  great  extent  influenced  by  the 
surrounding  temperature. 

There  are  numerous  occupations  involving  exposure  to  extremes  of  heat 
and  cold,  dampness  and  sudden  changes,  the  effect  of  which  will  be  briefly 
stated.  The  human  organism  possesses  the  faculty  of  maintaining  a  uniform 
temperature,  i.e.,  it  so  regulates  and  harmonizes  the  production  and  the  loss 
of  animal  heat  that  the  normal  temperature  of  the  blood,  98.2°F.  is  not  mate- 
rially affected.  In  this  the  skin  doubtless  plays  the  most  important  role. 
Whenever  cold  acts  upon  the  skin  the  irritation  is  primarily  exerted  upon  the 
28 


434        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

nerves  which  transmit  it  to  the  central  organs  of  the  nervous  system  (the 
heat  regulating  center)  and  from  there  it  is  reflected  to  the  nerves  of  the  cuta^ 
neous  vessels  and  muscular  fibers,  which  promptly  contract,  and  in  conse- 
quence of  a  diminished  blood  supply  there  is  less  loss  of  heat.  If,  on  the  other 
hand,  heat  instead  of  cold  acts  upon  the  skin,  we  have  dilatation  instead  of 
contraction  of  the  vessels,  with  an  increased  surface  blood  supply,  and  corre- 
sponding loss  of  heat  by  radiation  and  conduction.  At  the  same  time  the 
perspiratory  glands  are  stimulated  to  greater  activity,  more  sweat  is  excreted 
and  evaporated,  and  still  more  heat  is  dissipated.  One  of  the  bad  effects  of 
profuse  perspiration  is  that  the  blood  is  deprived  of  some  of  its  constituents. 
The  blood  is  taken  away  too  long  from  the  internal  organs,  the  proper  distri- 
bution of  the  blood  supply  is  interferred  with,  and  in  consequence  the  tone 
and  nutrition  of  the  stomach,  lungs,  heart,  and  other  internal  organs  is  lowered. 
We  lose  our  appetite  and  suffer  from  indigestion,  the  red  corpuscles  are  de- 
creased, we  experience  languor  and  general  enervation,  and  the  system  in 
consequence  is  rendered  more  susceptible  to  disease. 

While  the  human  organism  endeavors  to  adapt  itself  to  extremes  of  heat 
and  cold,  the  facility  of  the  body  to  maintain  the  equilibrium  is  by  no  means 
unlimited,  and  the  heat-regulating  center  is  liable  to  fail,  or  become  paralyzed 
if  imposed  upon  too  long  or  too  frequently.  This  is  especially  the  case 
during  sudden  changes  of  temperature.  It  is  the  abruptness  which  offends 
the  peripheral  nerves,  and  the  greater  the  abruptness  the  more  intensi^■L■ 
will  be  the  irritation  which  is  transmitted  by  reflex  action  to  other  parts  of 
the  body,  usually  the  weakest  parts.  This  may  result  in  driving  the  blood 
to  internal  organs,  causing  congestions  and  other  mischief.  Then  again 
a  cold  draft,  playing  on  the  skin,  may  cause  neuralgia,  paralysis,  sore-throat, 
bronchitis,  or  pneumonia,  showing  that  cold  appHed  locally  may  excite 
diseases  in  the  neighborhood  of  its  application  or  in  distant  organs,  and 
finally  it  may  produce  disease  by  checking  the  secretions  of  the  skin. 

Humidity. — The  atmosphere  always  contains  a  certain  amount  of  water 
in  the  state  of  vapor,  which  varies  from  30  per  cent,  to  complete  saturation, 
or,  according  to  temperature,  from  i  to  12  grains  in  a  cubic  foot  of  air.  The 
degree  of  atmospheric  humidity  is  of  special  hygienic  importance,  as  it  in- 
fluences to  a  great  extent  the  cutaneous  and  pulmonary  exhalation  of  vapor 
and,  in  consequence,  also  affects  the  animal  temperature.  The  average  daily 
amount  of  water  eliminated  by  the  skin  is  23^^  lb.  and  about  10  oz.  by  the 
lungs.  It  is  evident  that  when  the  air  is  damp  it  lessens  evaporation,  as  it 
possesses  little  drying  power,  and  the  water  from  the  skin  and  lungs  is  with 
difficulty  evaporated.  The  evaporation  of  perspiration,  by  which  heat  is 
rendered  latent,  is  one  of  the  chief  means  of  cooling  the  body.  Consequently 
when  the  air  is  hot  and  moist  the  humidity  tends  to  increase  the  effects  of 
the  heat,  the  blood  is  with  difficulty  kept  at  its  proper  temperature,  and  all 
the  disagreeable  effects  of  a  high  temperature  are  intensified.  This  con- 
dition may  be  so  aggravated  that  the  temperature  of  the  body  exceeds  the 


EXPOSURE    TO    EXCESSIVE   HEAT  435 

normal  degree  and  causes  our  cases  of  heat  stroke  or  heat  exhaustion,  which 
occur  especially  on  hot,  sultry  days. 

A  damp,  cold,  or  chilly  air  also  produces  mischief,  as  it  abstracts  an 
an  undue  amount  of  animal  heat,  lowers  the  general  vitality  of  the  system, 
and  favors  the  development  of  diseases  of  the  respiratory  passages,  neuralgic 
and  rheumatic  affections,  and  aggravates  the  severity  of  such  attacks.  We 
'may  conclude,  therefore,  that  excessive  humidity  tends  to  intensify  the  effects 
of  both  heat  and  cold.  On  the  other  hand,  excessive  dryness  of  the  air  is 
also  harmful.  It  increases  evaporation,  the  skin  becomes  dry  and  chapped, 
and  the  mucous  membranes  of  the  mouth,  eyes  and  respiratory  passages 
are  irritated,  causing  catarrhal  conditions. 

Exposure  to  excessive  heat  is  especially  common  in  stokers  and  firemen, 
smelters,  puddlers,  blast  and  electric  furnace  men,  steel  mill  and  foundry 
men,  blacksmiths,  glass-blowers,  kiln  and  pottery,  men,  bakers,  cooks,  miners, 
tunnel  workers,  malsters,  piano  polishers,  soldiers,  sailors,  roofers  and  all 
out-door  workers  during  hot  weather.  Exposure  to  dry  heat  for  a  short 
period  is  sometimes  borne  without  serious  effects  in  temperature  as  high  as 
140°  or  i5o°F.,  provided  the  air  is  kept  in  motion,  and  a  temperature  of 
2i2°F.  may  be  borne  by  puddlers  and  electric  furnace  men,  for  a  very 
brief  period,  without  serious  injury.  Prolonged  exposure,  however,  is  usu- 
ally followed  by  grave  constitutional  disturbances  already  referred  to. 
Apart  from  heat  exhaustion,  which  is  not  especially  common,  we  see  more 
frequently  as  acute  manifestation,  cases  of  colic,  concentrated  urine  and  mus- 
cular cramps,  which  symptoms  are  more  or  less  influenced  by  toxins  generated 
within  the  body;  cases  of  "colds, "  anaemia  and  general  debility  are  also  quite 
common  in  this  class  of  workers.  The  "colds"  are  due  to  the  pernicious  habit 
of  the  employees  in  passing  suddenly  from  an  overheated  atmosphere  to 
the  outer  air  during  the  cold  months.  As  already  stated,  any  abrupt  change 
in  temperature  is  liable  to  cause  congestion  of  internal  organs;  hence  the 
undue  frequency  of  catarrhal,  neuralgic  and  rheumatic  affections  among 
imprudent  workers.  These  congestions  not  infrequently  also  result  in  gastro- 
intestinal and  vesical  catarrh,  and  pave  the  way  for  pneumonia,  pleurisy 
and  Bright's  disease.  The  men  engaged  in  handling  molten  metal,  and  all 
others  exposed  to  radiant  heat,  not  infrequently  suffer  from  dermatitis  and 
pigmentation  of  the  skin,  inflammatory  conditions  of  the  eyes,  and  even 
cataract,  probably  induced  by  a  partial  dehydration  of  the  tissues.  Nervous 
affections,  such  as  headache,  dizziness  and  general  irritability,  are  also  ob- 
served. Exposure  to  intense  solar  heat  is  not  uncommon  among  out-door 
workers,  and  cases  of  sunburns  and  sunstroke  occasionally  occur.  Sun- 
stroke is  evidently  caused  by  a  congestion  and  inflammation  of  the  cerebral 
membranes,  in  which  not  only  heat  but  the  ultra-violet  rays  may  play  a 
role.  Heat  combined  with  humidity  is  especially  trying  to  workers  in  brew- 
eries, laundries,  kitchens,  hot  houses,  tanneries,  canneries,  and  sugar  re- 
fineries, but  cases  of  heat  exhaustion  may  occur  in  all  occupations  involving 


436         ETIOLOGY    AND    PROPHYLAXIS    OF    OCCUPATIONAL    DISEASES 

hard  work  in  a  hot  and  sultry  atmosphere.  Affections  of  the  skin,  such  as 
cystic  degeneration  of  the  sweat  ducts,  are  not  uncommon  in  laundry 
workers  and  others  exposed  to  a  steaming  atmosphere. 

The  effects  of  exposure  to  excessive  cold  are  usually  not  so  serious,  as  they 
are  generally  guarded  against  by  suitable  clothing  and  food  rich  in  fats  and 
carbohydrates.  The  persons  chiefly  affected  are  ice  men,  cold  storage 
workers,  butchers,  brewery  men,  in  the  cooling  department,  and  out-door 
workers  such  as  lumbermen,  aviators,  farmers,  teamsters,  coachmen,  etc. 
In  this  instance,  also,  any  sudden  change  of  temperature  is  liable  to  engender 
internal  congestions.  Among  the  local  effects  may  be  mentioned  frost 
bites  and  eczema. 

Occupations  involving  exposure  to  a  cold  and  humid  atmosphere  are  in- 
jurious, because  a  cold  damp  air  abstracts  an  undue  amount  of  animal  heat 
from  the  body,  lowers  the  power  of  resistance,  and  predisposes  to  catarrhal, 
rheumatic  and  pulmonary  diseases. 

Preventive  Measures. — -The  most  agreeable  temperature  for  average 
healthy  adults  performing  ordinary  light  work  is  between  65  and  7o°F., 
but  a  lower  temperature  is  desirable  for  persons  engaged  in  hard  work. 
Every  effort  should  be  made  to  avoid  extremes  of  heat  and  cold.  Much 
may  be  done  to  reduce  the  temperature  of  workshops  by  forced  ventilation 
and  a  supply  of  cool  fresh  air.  The  windows  should  be  kept  open  and  the 
air  kept  in  motion.  Special  cooling  devices  and  screens  have  been  designed 
for  blast  furnaces,  etc. 

Since  an  average  relative  humidity  between  55  and  65  per  cent,  has  been 
found  most  healthful,  efforts  should  be  made  to  maintain  such  a  standard 
whenever  practicable.  Apart  from  methods  calculated  to  accomplish  this 
result,  reliable  thermometers  and  hygrometers  are  required  for  efficient  con- 
trol. Legislators  would  do  well,  instead  of  making  a  general  provision  for 
"sufficient  heat,  moisture,  etc.,  to  prescribe  a  standard,  at  least  in  industries 
where  such  standards  are  practicable  and  can  be  reasonably  enforced. 

The  EngHsh  regulations  for  the  textile  industries  prescribe  that  the  tem- 
perature shall  not  fall  below  5o°F.  and  "the  humidity  of  the  air  shall  not  at 
any  time  be  such  that  the  difference  between  the  readings  of  the  wet-  and  dry- 
bulb  thermometers  is  less  than  2°." 

Many  of  the  injurious  effects  of  exposure  to  extremes  of  heat  and  cold  can 
be  guarded  against  by  suitable  clothing,  avoidance  of  abrupt  changes,  fre- 
quent bathing  and  systematic  hardening  of  the  skin. 

Abnormal  Atmospheric  Conditions. — The  effect  of  compressed  air  upon 
the  workmen  in  caissons  and  diving  apparatus  have  been  presented  in  the 
chapter  on  caisson  disease,  and  the  effects  of  rarified  air  upon  mountain 
climbers,  baloonists,  aviators  and  workers  in  high  altitudes  have  been  de- 
scribed on  page  211.  The  effects  of  air  concussion  and  excessive  noises  have 
been  considered  in  the  chapter  on  diseases  and  injuries  of  the  ear. 

Abnormal  Light  Conditions. — The  effects  of  excessive  or  defective  light 


ABNORMAL    LIGHT    CONDITIONS  437 

are  set  forth  in  the  chapter  on  diseases  and  injuries  of  the  eye,  and  it  remains 
for  us  to  emphasize  here  the  principles  which  should  govern  the  subject  of 
lighting. 

Natural  Light. — ^The  natural  light  in  workshops  should  be  sufficient,  so 
that  the  eyes  need  not  be  strained  even  on  cloudy  days.  When  the  light  is 
defective  the  objects  have  to  be  brought  too  near.  The  eyes  in  consequence 
converge.  The  muscular  strain  thus  produced  causes  a  gradual  elongation 
of  the  anterior-posterior  axis  of  the  eyeball,  and  nearsightedness  results. 
It  is  believed  by  specialists  that  80  to  90  per  cent,  of  the  headaches  are  due 
to  eye  strain  caused  by  defective  light,  also  numerous  cases  of  backaches, 
anaemias,  and  general  impairment  of  health.  In  addition  there  is  good 
reason  to  believe  that  defective  lighting  influences  the  number  of  industrial 
accidents,  the  efficiency  of  production,  the  quality  of  the  product  and  the 
cleanliness,  cheerfulness  and  healthfulness  of  the  shop. 

It  has  been  found  by  Putzeys^^  that  the  natural  lighting  in  temperate 
climates  will  usually  come  up  to  hygienic  requirements  when  the  area  of 
windows,  exclusive  of  sash  frames,  equals  one-sixth  of  the  floor  space.  In 
order  that  the  light  may  penetrate  the  deeper  portions  of  the  room,  the 
windows  should  reach  almost  to  the  ceiling  and  the  glass  should  be  either 
pure  white  or  prismatic,  and  kept  clean. 

The  difficulty  of  securing  a  sufficient  amount  of  daylight  in  buildings 
located  in  narrow  streets,  surrounded  by  tall  buildings,  has  been  partly 
overcome  by  glass  building  blocks  8  by  6  by  2}4,  in.,  with  an  air  chamber  in 
the  center,  used  instead  of  bricks  or  stone,  in  connection  with  steel-frame 
construction,  but  more  particularly  by  the  introduction  of  prismatic  glass, 
which  refracts  and  diffuses  the  light. 

Artificial  light,  no  matter  how  obtained,  differs  from  daylight  in  this, 
that  it  does  not  furnish  a  pure  white  light,  the  prevailing  rays  being  red,  yel- 
low or  violet.  Whatever  difference  of  opinion  there  may  be  as  to  the  color 
best  suited  to  the  eye,  we  know  that  vision  is  most  perfect  under  the  influence 
of  white  light,  and  this  ought  to  be  a  good  criterion.  One  of  the  disadvan- 
tages of  all  low-power  illuminants  is  that  the  light  is  never  as  bright  as  day- 
light, involving,  therefore,  closer  application  of  the  eyes  and  consequent 
strain  of  the  muscles  of  the  eyeball.  These  remarks  are  hardly  applicable 
to  the  electric  arc  light  and  the  Welsbach  gas-burner,  the  rays  of  which,  like 
the  direct  solar  rays,  may  indeed  be  so  glaring  as  to  cause  undue  irritation 
of  the  retina. 

Another  harmful  effect  of  artificial  illumination  is  the  unsteady  or  flick- 
ering character,  especially  seen  in  the  electric  arc  light,  which  on  account  of 
the  abrupt  changes  is  likely  to  irritate  the  retina.  Another  disadvantage 
is  that  the  ordinary  illuminants,  except  the  electric  light,  tend  to  vitiate  the 
air  by  the  products  of  combustion,  and  also  affect  the  temperature  and  hu- 
midity of  the  air  by  the  heat  evolved. 

The  requirements  of  a  hygienic  Hght  are  that  it  should  be  as  near  as 


438         ETIOLOGY    AND    PROPHYLAXIS    OF    OCCUPATIONAL    DISEASES 

possible  the  color  of  the  sunlight,  sufficiently  ample  but  not  too  glaring. 
It  should  be  steady,  and  instead  of  deteriorating  the  air  it  should  as  far  as 
practicable  be  utilized  to  promote  ventilation;  nor  should  the  heat  evolved 
be  sufficiently  intense  to  be  a  source  of  discomfort  to  the  inmates  in  warm 
weather.  The  most  common  methods  of  lighting  now  employed  are  the 
electric  incandescent  lamps,  arc  lights,  mercury-vapor  lights,  electric  bulbs, 
gas  light  and  kerosene  lamps.  Of  these,  electric  light,  especially  the  indirect 
system  of  lighting,  is  superior  to  gas  or  other  illuminants,  because  there  is 
little  or  no  danger  from  fire,  and  there  are  no  products  of  combustion,  hence 
no  pollution  of  the  air.  Nor  are  the  temperature  and  humidity  of  the  room 
affected  to  any  perceptible  extent.  These  advantages  over  gas  or  kerosene 
are  of  special  importance  to  the  inmates  of  buildings  where  the  question  of 
fresh  air  and  temperature  plays  an  important  role.  Hence  many  industrial 
plants  find  it  profitable  to  install  the  very  best  type  of  electric  lighting,  and 
thereby  save  time  and  money  by  the  prevention  of  sickness  and  accidents 
among  their  employees.  Next  to  the  electric  light,  gas,  especially  in  con- 
nection with  a  Welsbach  or  Siemen's  burner,  or  acetylene  gas,  ofifers  the  best 
choice.  In  the  absence  of  either  electric  or  gas  light,  kerosene,  with  a  high 
flashing  point,  should  be  preferred  over  other  illuminants.  Suitable  out- 
lets for  the  products  of  combustion  should  always  be  provided. 

White,  clean  ceilings  and  walls  will  be  of  great  service,  not  only  in  solving 
the  question  of  light  but  also  in  general  sanitation.  A  number  of  States  re- 
quire the  walls  to  be  limewashed  or  painted. 

The  sufficiency  of  artificial  lighting  may  be  approximately  determined 
by  observation,  and  quite  accurately  by  the  employment  of  Bunsen's  method 
and  his  photometer.  In  this  country  and  in  England,  according  to  Munson, 
"the  unit  adopted  for  the  measurement  and  comparison  of  lights  is  a  No.  6 
sperm  candle  burning  8  grams  per  hour  and  giving  out  a  light  known  as 
I  candle-power."  Such  a  candle  contains  on  analysis  carbon  80  per  cent., 
hydrogen  13  per. cent.,  oxygen  6  per  cent.,  and  in  combustion  yields  to  the 
air  equal  volumes  of  carbonic  acid  and  watery  vapor,  namely,  0.41  cu.  ft. 

Dust  and  Fumes. — The  relation  of  dust  to  occupational  diseases  is 
extremely  important  and  its  effects  upon  the  respiratory  organs  have  been 
considered  by  Sir  Thomas  Oliver  in  the  Chapter  on  Pneumokoniosis.  The 
desirability  of  differentiating  fibroid  phthisis,  according  to  the  nature  of  the 
foreign  particles  or  exciting  cause,  has  given  rise  to  special  designations.  So, 
for  example,  fibroid  phthisis  caused  by  coal  dust  has  been  called  anthracosis, 
by  flinty  or  silicous  particles,  chalicosis  or  silicosis,  from  clay  dust  alumitwsis, 
from  steel,  iron  or  iron  oxide,  siderosis,  from  tobacco,  tabacosis,  from  cotton 
or  linen  dust,  bysinosis,  and  from  feather  and  down  dust  (Watkins-Pitch- 
ford^^  has  recently  coined  the  term)  "ptilosis"  with  special  reference  to  the 
ostrich  feather  industry  in  South  Africa. 

Ahrens^^  found  the  amount  of  dust  per  cubic  meter  of  air  in  different 
establishments  as  follows: 


DUST    AND    FUMES  439 

Mg.  Mg. 

Horse-hair  works 10. o  Flour  mill 28.0 

Sawmill 17.0  Foundry 28.0 

Woolen  factory 20.0  Foundry  polishing  room 71.7 

Woolen  factory  with  exhaust  ventila-  Felt-shoe  factory 175 -O 

tion 7.0 

Paper  factory 24.0  Cement  works 224.0 

Laboratory 1.4 

Dr.  Graham  Rogers^*  found  70  grains  of  dust  per  million  liters  of  air  in 
a  skirt  factory,  about  the  same  amount  in  a  pearl  button  factory,  and  75 
grains  in  the  air  of  a  brass  foundry. 

According  to  Schuler  and  Burkhardt,  cited  by  Roth,^"  the  morbidity  per 
1000  workers  in  dusty  trades  is  as  follows: 

Bookbinders 98  Paper-factory  employees 343 

Silk  weavers 205  Mechanical  industrial  shops 419 

Cotton  spinners 250  Wood  turners 427 

Cotton  weavers 285  Rag  sorters  in  paper  mill 429 

Typefounders  and  typesetters 304 

Dust,  apart  from  its  relation  to  respiratory  diseases,  also  plays  an  im- 
portant role  in  diseases  of  the  eye,  ear,  nose  and  throat,  as  instanced  by  an 
undue  prevalence  of  chronic  inflammatory  conditions  of  these  organs  in  lime, 
cement  and  hair  workers,  and  by  the  frequent  occurrence  of  ulcerations  of 
the  nasal  septum  in  chrome,  chlorine  and  cement  workers.  It  has  also  been 
shown  that  even  flour  and  sugar  dust,  usually  considered  quite  free  from 
danger,  may  be  converted  into  lactic  acid  in  the  mouth  and  possibly  increase 
the  virulence  of  disease  germs,  as  evinced  by  an  undue  prevalence  of  caries 
and  pneumonia  in  flour  and  sugar  workers.  The  dust  generated  in  the  manu- 
facture of  pearl  buttons,  from  the  shells  of  certain  mussels,  is  liable  to  pro- 
duce a  peculiar  form  of  osteomyelitis,  involving  especially  the  long  bones  of 
youthful  workers,  and  other  affections  noted  under  mother  of  pearl  workers. 
A  combination  of  dust,  sweat  and  heat,  also  favors  the  development  of 
skin  diseases,  as  seen  by  the  undue  prevalence  of  furuncles  and  eczema  in 
persons  exposed  to  mineral,  metallic,  sugar,  flour,  aniline  and  other  dusts. 
Since  dust  and  germs  often  go  hand  in  hand,  there  is  little  doubt  that  in 
many  instances  occupational  infections  are  conveyed  by  means  of  infected 
dust. 

The  effects  of  smoke  and  soot  upon  the  health  of  workers  and  the 
community  has  been  studied  by  Ascher  of  Germany,  and  by  numerous 
antismoke-  commissions  both  here  and  abroad.  The  results  everywhere 
show  a  distinct  relationship  between  the  smoke  nuisance  and  diseases  of 
the  respiratory  organs,  especially  pneumonia. 

The  injurious  effect  of  dust  in  all  its  forms  cannot  be  questioned  and  is 
made  sufflciently  apparent  by  a  study  of  tuberculosis  in  relation  to  dusty 
trades.     Fortunately  only  about  25  per  cent,  of  the  dust  inhaled  actually 


440        ETIOLOGY    AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

reaches  the  lungs,  the  bulk,  according  toLehmann  and  his  pupils,  is  swallowed. 
But  this  does  not  imply  that  the  dust  which  has  found  its  way  through 
the  stomach  remains  harmless,  for  it  may  reach  the  lungs  by  way  of  the 
lymph  channels,  and  certainly  all  poisonous  dusts  can  be  absorbed  in  the 
gastrointestinal  canal.  fl 

In  addition  to  the  mechanical,  irritant  and  toxic  character  of  dust, 
Haldane  very  properly  points  out  that  "it  inevitably  tends  to  lower  the 
social  status  and  self-respect  of  the  work  people." 

Preventive  Measures. — The  subject  of  dust  prevention,  and  its  removal 
when  its  formation  is  unavoidable,  is  one  of  the  most  important  problems. 
Thanks  to  the  efforts  of  technical  experts,  most  commendable  progress  has 
been  made  in  the  following  directions: 

(a)  Prevention  oj  Dust  Formation. — There  are  a  number  of  occupations 
in  which  dust  production  can  be  reduced  to  a  minimum  by  the  application 
of  oil,  sprays  of  water,  or  jets  of  steam.  The  wet  processes  are  especially 
applicable  to  the  metal,  lead  and  pottery  industries,  to  rock  drilling,  mining, 
blasting,  stone  crushing,  and  cutting,  etc.  Dr.  Watkins-Pitchford,^°  in  dis- 
cussing the  etiology  and  prevention  of  phthisis  among  the  Rand  miners,  with 
a  notoriously  high  morbidity  rate,  viz.,  32  per  cent,  and  a  death  rate  of  13.8 
per  1000,  tells  us  that  in  December,  1912,  there  were  5600  rock  drills  in  opera- 
tion. He  describes  in  detail  the  present  methods  of  drilling  and  how  the 
dangerous  quartzite  dust,  as  soon  as  it  is  formed,  is  converted  into  mud  by 
keeping  the  drill  hole  and  surroundings  wet  with  water.  This  may  be  done 
by  means  of  a  syringe  or  spraying  apparatus,  while  some  types  of  rock  drills 
provide  for  the  automatic  flushing  of  the  hole.  In  blasting  operations  similar 
good  results,  in  laying  dust,  have  been  attained  by  the  application  of  water 
spray,  or  steam,  just  before  the  charge  is  fired.  This  is  not  only  important  in 
the  prevention  of  dust  inhalation,  but  also  to  prevent  disastrous  explosions 
of  coal  dust  in  coal  mines. 

Dr.  Watkins-Pitchford-"  declares,  ''It  is  no  mere  euphemism  to  say  that 
a  scrupulous  obedience  to  the  spirit  of  the  present  Mining  Regulations  will 
result  in  the  total  abolition  of  pulmonary  silicosis  from  the  gold  fields  of  the 
Rand."  General  Gorgas  in  a  more  conservative  way  says,  "I  advise  that 
such  measures  be  generally  and  carefully  enforced  and  extended.  I  believe 
they  will  soon  reduce  miners'  phthisis  to  a  minimum."  See  also  miners, 
page  622. 

(b)  Prevention  of  Dust  and  Fume  Dijfiision.— Technical  experts  have 
done  much  to  prevent  the  escape  of  dust  and  fumes  at  the  point  of  origin, 
by  enclosing  the  machinery  or  apparatus  in  air-tight  cases.  This,  however, 
prevents  the  diffusion  of  dust  and  fumes  only  when  no  opening  or  hand  feed- 
ing is  required,  and  hence  the  attempt  to  substitute  as  far  as  practicable 
automatic  feeding  machinery  for  hand  labor.  There  are,  however,  many 
processes  in  which  wholly  enclosed  machinery  is  impracticable  and  ineffective, 
and  hence  additional  methods  must  be  invoked. 


DUST    AXD    FUMES  44I 

(c)  Remvval  of  Dust  and  Fumes. — This  is  accomplished  by  mechanical 
devices  connected  with  a  system  of  exhaust  ventilation.  Fortunatelv  quite 
a  number  of  states  have  made  statutory  provisions,  for  the  removal  of  dust 
and  fumes,  which  lay  down  specific  rules  concerning  the  construction  of 
work  benches  and  hoods  or  hoppers.  The  hoods  are  usually  made  of  metal 
and  so  arranged  and  applied,  that  the  dust  will  be  thrown  by  centrifugal 
force  into  the  hood  and  carried  off  by  the  current  of  air  into  a  suction  pipe 
attached  to  the  hood  or  hopper.  The  suction  pipes  attached  to  different 
hoods  enter  a  main  suction  pipe  at  an  angle  of  30-45°.  The  main  or  trunk 
line  is  usually  below  the  floor  and  empties  into  a  discharge  pipe,  connected 
with  an  exhaust  fan,  run  at  such  a  rate  of  speed  as  will  produce  a  velocity 
of  air  sufficient  to  carry  off  the  dust  and  fumes.  It  is  extremely  important 
that  the  mechanism  is  so  arranged,  that  the  dust  and  fumes  are  drawn  away 
from  the  face  of  the  worker,  i.e.,  downward  and  backward.  The  details  of 
an  efficient  exhaust  system  must  be  worked  out  and  adapted  to  the  needs  of 
different  industrial  plants,  by  a  competent  ventilation  engineer. 

{d)  Collection  of  Dust  and  Fumes.— In  the  interest  of  public  health  and 
for  economic  reasons,  in  certain  industries,  the  dust  and  fumes  extracted  by 
the  preceding  methods  should  be  collected,  treated  and  disposed  of  in  a 
suitable  manner.  In  the  case  of  toxic  fumes  and  gases  this  is  usually 
accomplished  by  (i)  condensation,  (2)  absorption  by  water  or  chemicals,  (3) 
destructive  distillation  by  heat  in  a  closed  vessel,  (4)  combustion  of  gases  that 
can  be  burned,  and  (5)  discharge  of  gases  into  the  air  at  great  height. 

The  material  recovered  by  condensation  and  absorption  constitutes  often 
a  valuable  by-product  of  the  industry.  The  value  of  blast-furnace  and 
coke-oven  gases  is  evinced  by  their  utilization  as  fuel  for  heat  and  power, 
and  the  sulphurous  fumes  evolved  in  spelter  works  are  converted  into 
sulphuric  acid. 

In  the  case  of  dust  which  has  no  special  value,  it  is  usually  made  to  pass 
through  a  tower  and  precipitated  by  means  of  a  fine  spray  of  water.  For  the 
recovery  of  valuable  constituents,  as  in  the  jew^elry  industry,  the  dust  is 
collected  in  suitable  tanks  under  water  for  the  ultimate  recovery  of  gold 
or  silver.  The  collection  of  large  particles  of  dust  is  usually  accomplished 
by  means  of  so-called  cyclone  separators  in  which,  by  means  of  centrifugal 
force  and  a  cone-shaped  metallic  drum,  the  dust  is  deposited. 

A  very  efficient  method  is  filtration  of  the  air,  through  jute  or  cheese 
cloth,  woolen  sheets  or  fine  wire  mesh.  The  filter  devised  by  Beth  is  supplied 
with  a  mechanical  knocking  device  ''which  shakes  the  dust  from  the  screen- 
ing material  to  the  bottom  of  the  casing,  where  a  worm  automatically  carries 
it  to  the  collecting  receptacle." 

In  addition  to  these  methods  successful  attempts  have  been  made  to 
precipitate  dust  and  smoke  by  strong  electric  currents.  A  method  devised 
by  Cottrell,  in  connection  with  some  cement  works  in  Southern  California, 
has  demonstrated  that,  by  means  of  a  large  electrified  chamber,  from  95  to 


442         ETIOLOGY    AND    PROPHYLAXIS    OF    OCCUPATIONAL    DISEASES 

98  per  cent,  of  the  cement  dust,  from  escaping  gases  during  the  roasting 
process,  can  be  precipitated  and  collected. 

{e)  Respirators. — There  are  times  when,  in  the  absence  of  proper  safe- 
guards, or  because  of  unavoidable  working  conditions,  the  employment  of 
respirators  becomes  necessary.  There  is  an  endless  variety  of  these  devices 
in  the  market,  all  intended  to  filter  out  dust  and  fumes,  by  means  of  sponge, 
cotton  wool  or  gauze.  It  should  be  remembered  that  even  the  best  respira- 
tors, so  far  designed,  are  far  from  satisfactory,  and  none  fulfil  the  indications 
fully.  Indeed  some  of  the  respirators  improvised  by  the  workers,  consisting 
of  a  piece  of  sponge,  cheese-cloth,  jute,  etc.,  fastened  by  means  of  elastics  over 
nose  and  mouth  are  quite  as  effective  as  most  of  the  manufactured  appliances. 

The  working  conditions  should  be  so  perfect  as  to  obviate  the  use  of  res- 
pirators.    Until  this  is  accomplished  their  employment  should  be  encouraged. 

(/■)  Cleaning  of  Workshops. — A  number  of  states  provide  by  law  that 
''all  factories  shall  be  kept  clean."  It  is  difficult  to  set  up  exact  standards, 
for  what  is  clean  in  a  blacksmith  shop  would  not  be  clean  in  a  shirt-waist 
factory.  But  it  is  well  to  emphasize  the  fact,  that  no  amount  of  ventilation 
can  do  away  with  the  necessity  for  frequent  and  systematic  shop  cleaning. 
Hygiene  demands  that  there  should  be  no  accumulation  of  dust  in  any  part 
of  the  premises,  and  therefore  condemns  all  interior  finishes,  such  as  exposed 
girders,  cornices,  mouldings,  cubby  holes,  unnecessary  shelves  and  inaccess- 
ible spaces,  which  will  serve  as  dust  and  germ  traps. 

Hygiene,  on  the  other  hand,  approves  of  hard  wood  or  impermeable  floors, 
curves  instead  of  corners  and  angles,  smooth  and  non-absorbent  walls — in 
brief  of  everything  which  will  prevent  the  collection  of  dust  and  germs  and 
facilitate  their  removal. 

Workshops  should  be  swept  daily  after  cessation  of  work,  the  sweeping 
should  be  done  when  practicable  with  damp  saw  dust,  with  the  upper  windows 
opened.  In  certain  industries,  cleaning  and  dusting  by  the  vacuum  system 
has  been  practised  and  should  be  encouraged,  especially  where  there  is  expo- 
sure to  poisonous  dust.  All  work  benches  and  tables  should  be  carefully 
cleansed,  and  wiped  with  a  damp  cloth  for  the  removal  of  fine  dust.  Feather 
dusters  do  not  remove  but  simply  displace  dust.  In  a  num.ber  of  occupations, 
cement  floors,  with  a  suitable  incline  for  drainage,  so  as  to  facilitate  washing 
with  hose,  have  been  found  very  useful.  The  application  to  floors  of  so- 
called  "dust  oil"  cannot  be  approved  since  it  simply  allays  dust,  but  does  not 
remove  it,  and  is  therefore  especially  objectionable  in  industries  where  poi- 
sonous dust  is  given  off. 

Miscellaneous  Sanitary  Provisions.— In  this  connection  it  is  desirable  to 
point  out  certain  sanitary  requisites,  which  are  important  in  all  dusty  occu- 
pations, especially  in  those  involving  exposure  to  toxic  dust  and  fumes. 

I.  Suitable  Work  Clothes  and  Caps. — There  is  a  great  variety  of  suitable 
patterns  in  the  market,  of  which  the  snug-fitting  duck  union  suit,  without 
many  folds,  properly  buttoned  and  adjusted  is  the  best.      Such  suits  and 


ABNORMAL   POSITIONS    OF    THE   BODY  443 

caps  should  be  furnished  at  the  expense  of  the  employer  and  washed  once  a 
week.  In  occupations  involving  contact  with  poisonous  liquids,  rubber  gloves 
and  impermeable  overalls  or  aprons  offer  the  best  protection.  For  all  wet 
processes  impermeable  clothing  or  aprons  should  be  worn.  Asbestos  cloth- 
ing has  been  recommended  for  firemen,  etc.,  but  its  weight  is  objectionable, 
and  light  leather  suits  or  aprons  are  preferable.  Ordinary  work  suits  may  be 
rendered  practically  non-inflammable  by  chemical  treatment. 

2.  Dressing-rooms,  Lockers,  Bath  and  Wash  Rooms. — It  is  desirable,  in  all 
dusty  occupations,  that  the  workmen  should  take  off  all  their  street  clothing 
before  beginning  work,  and  this  is  absolutely  essential  when  the  occupation 
involves  exposure  to  poisonous  dust.  For  this  purpose  suitable  dressing- 
rooms,  provided  with  lockers  for  street  suits  and  separate  compartments  for 
overalls,  are  necessary.  Facilities  for  washing  and  bathing,  brushes,  soap  and 
individual  towels  should  be  furnished.  In  most  of  the  civilized  countries 
statutory  provisions  have  been  made  for  these  sanitary  requisites,  in  all  estab- 
lishments in  which  poisonous  substances  are  manufactured  or  used,  and  the 
result  has  been  most  beneficial.  It  is  important  that  workers  should  be  in- 
structed to  wash  their  mouths  and  teeth  before  eating  and  upon  cessation  of 
work.  Indeed  it  is  a  good  habit  to  rinse  the  mouth  before  swallowing  even 
water,  as  much  of  the  injurious  dust  lodged  in  the  mouth  will  find  its  way  into 
the  stomach. 

3.  Pure  Drinking  Water  and  Lunch  i?o<9W5.— Hard  work  and  dusty  occu- 
pations produce  thirst,  and  hence  the  necessity  of  an  ample,  easily  accessible 
pure  and  cool  supply  of  drinking  water.  Sanitary  fountains  are  coming  more 
and  more  in  evidence  in  factories  and  workshops.  The  health  and  safety  of 
employees  exposed  to  industrial  poisons  demand  that  no  food  shall  be  taken, 
or  tobacco  in  any  form  used,  in  the  workrooms.  A  commendable  number  of 
establishments  have  provided  special  lunch  rooms  in  connection  with  their 
dressing-rooms  where  either  their  own  food  can  be  warmed  up,  or  rolls,  sand- 
witches,  coffee,  tea,  milk,  soft  drinks,  fruit  juice  and  hot  soups  may  be  ob- 
tained at  a  nominal  cost.  Coffee  and  tea  allay  thirst  and  are  stimulants, 
without  the  depressing  effect  of  alcohol  and  their  use  has  materially  lessened 
the  evils  of  intemperance.  Milk  is  especially  recommended  for  workers  in 
the  lead  and  aniline  industries  and  is  often  supplied  free  of  charge. 

Abnonnal  Positions  of  the  Body. — The  effects  of  a  constrained  working 
position,  combined  with  a  sedentary  life,  have  been  briefly  mentioned  in  con- 
nection with  indoor  occupations.  The  effects  are  especially  harmful  in  youth- 
ful workers  whose  osseous  system  is  not  fully  developed  and  there  is  little 
doubt  that  most  of  the  bone  and  joint  deformities  are  developed  in  the  earlier 
years  of  their  work,  and  aggravated  by  habit.  Among  the  more  important 
should  be  mentioned  the  hollow  chest  and  round  stooped  shoulders,  caused  by 
a  stooped  and  cramped  position,  as  seen  especially  in  tailors,  engravers,  lithog- 
raphers, watchmakers,  metal  grinders,  shoemakers,  and  all  others  obliged  to 
assume  a  more  or  less  bent-over  posture.     In  shoemakers   (cobblers)  the 


444         ETIOLOGY    AND    PROPHYLAXIS    OF    OCCUPATIONAL    DISEASES 

pressure  of  the  last  against  the  breast  bone,  aggravates  the  anterior  compres- 
sion and  often  causes  a  typical  depression  of  the  sternum.  All  thoracic  pos- 
tural deformities  naturally  interfere  with  free  expansion  of  the  lungs,  and 
hence  with  the  respiratory  functions.  A  stooped  or  bending  posture  also 
interferes  with  the  proper  distribution  of  the  blood  supply,  and  invites  con- 
gestions of  the  abdominal  and  pelvic  organs. 

As  a  matter  of  fact,  a  large  number  of  this  class  of  artisans  show  a 
peculiar  predisposition  to  consumption,  many  suffer  from  anaemia,  constipa- 
tion, dyspepsia,  and  hemorrhoids,  and  the  majority  have  a  low  average 
duration  of  life. 

Round  shoulders  and  lateral  curvature  of  the  spine  are  quite  common  in 
bearers  of  burdens,  and  in  all  occupations  involving  the  elevation  of  one 
shoulder  above  the  other,  so  that  even  a  clerk  by  a  faulty  position,  or  in  the 
absence  of  an  adjustable  chair,  may  acquire  lateral  curvature  of  the  spine. 
Such  deformities  are  also  quite  common  in  blacksmiths,  locksmiths,  cabinet- 
makers and  others,  largely  because  of  faulty  posture  and  workbenches,  and 
also  on  account  of  the  unequal  development  of  certain  muscular  groups. 

Among  youthful  workers,  especially  apprentices  of  bakers  barbers, 
waiters,  nurses,  etc.,  "flat-foot"  "knock-knee,"  and  "in-knee"  and  varicose 
veins  of  the  lower  extremity  are  frequently  observed,  as  a  result  of  being 
on  their  feet  too  long.  Varicose  veins,  eczema,  and  ulcers  are  also  quite 
common  in  motormen,  conductors,  machine  tenders,  and  others  who  are 
obliged  to  be  standing  the  greater  part  of  their  working  hours.  Shultes-^ 
found  varicose  veins  in  12.2  per  cent,  of  German  recruits,  who  had  pursued 
an  occupation  involving  a  standing  position,  4  per  cent,  in  those  who  stood 
and  walked,  and  i  per  cent,  in  those  engaged  in  a  more  sedentary  position, 
and  none  in  those  whose  occupation  was  wholly  sedentary. 

Abnormal  position  combined  with  pressure  is  responsible  for  muscular 
cramps,  sciatica,  and  neuralgic  affections.  The  so-called  'housemaid's 
knee,"  which  is  an  enlargement  of  the  patellar  bursae  tilled  with  fluid  is 
notoriously  common,  not  only  in  scrubber  women,  but  in  floor  finishers, 
carpet  layers,  and  others  who  are  obliged  to  be  upon  their  knees  for  a  con- 
siderable time.  This  same  factor  also  plays  an  important  role  in  the  causa- 
tion of  the  miners  "beat  knee,"  which  is  a  subcutaneous  cellulitis  over  the 
knee-cap. 

Preventive  Measures, — Experience  has  shown  that  many  of  these  de- 
formities can  be  prevented  by  teaching  apprentices  proper  posture.  Indeed 
in  view  of  the  fact  that  so  many  of  these  physical  defects  disqualify  men  for 
military  service,  it  seems  desirable  that  this  training  should  be  begun  in 
the  school.  This  can  be  done  by  the  universal  use  of  adjustable  seats  and 
desks,  correction  of  faulty  positions,  and  exercise  of  opposing  groups  of 
muscles.  In  the  factory  or  workshop  adjustable  seats  and  proper  work- 
benches are  of  equal  importance,  and  all  persons  engaged  in  occupations 
involving  constrained  attitudes  should  be  encouraged   to  engage  in  well 


FLAT    FEET  445 

regulated  gymnastic  exercises.  A  number  of  states  make  seats  for  females 
obligatory;  there  is  no  good  reason  why  this  provision  should  not  be  extended 
to  include  men,  whenever  it  is  practicable.  For  the  prevention  of  "house- 
maid's knee"  suitable  knee  pads  should  be  used. 

For  the  relief  of  varicose  veins  and  prevention  of  leg  ulcers,  massage, 
rubber  bandages,  or  elastic  stockings  are  indicated. 

Flat-feet. — Captain  J.  R.  Harris  of  the  Medical  Corps  U.  S.  A.  has  written 
an  excellent  article"^-  on  this  subject  and  concludes  that  the  prime  cause  of 
fiat  or  weak  feet  is  improper  posture  and  gait.  For  the  correction  and 
prevention  of  flat-feet  he  recommends  the  following: 

"The  habitual  position  in  standing  should  be  the  position  of  attention, 
except  that  the  heels  should  be  i  or  2  in.  further  apart  than  the  toes.  This 
is  a  position  of  muscular  tonicity  and  readiness  in  which  the  position  of 
the  astragalus  and  the  integrity  of  the  arch  are  maintained. 

The  stride  is  changed  from  the  usual  waddle  gait  to  the  proper  gait 
by  teaching  the  Indian  stride  until  the  reflex  centers  in  the  lumbar  cord 
shall  have  learned  the  new  routine,  usually  a  matter  of  a  few  lessons  only. 
Then  reduction  of  the  exaggeration  is  permitted,  and  a  set  of  corrective  and 
strengthening  exercises  prescribed  such  as  the  following: 

1.  Rise  upon  the  tip  toes  as  high  as  possible  and  lower  the  heels  again 
slowly. 

2.  Raise  the  toes  as  high  as  possible  and  relax. 

3.  Raise  the  body  by  pinching  or  pressing  downward  with  all  the  toes, 
an  action  similar  to  "grasping"  with  the  hands,  endeavoring  not  to  use  the 
leg  rriuscles. 

4.  Cross  the  right  foot  in  front  of  the  left  and  sway,  carrying  the  weight 
alternately  from  the  left  to  the  right  foot,  with  active  pushing  of  the  toes. 
Reverse  the  feet  and  repeat  the  exercise. 

5.  Stand  with  the  left  foot  in  the  hollow  of  the  right  knee  and  swing 
about  balanced  on  the  right  foot.  Change  and  balance  on  left  foot.  Con- 
tinue each  exercise  from  5  to  10  minutes  according  to  the  effect  upon  the 
muscles.     Repeat  all  the  above  several  times  each  day. 

These  exercises  are  best  taken  in  barefeet.  It  will  be  sufficient  in  many 
cases  to  stand  with  the  toes  turned  well  in,  draw  up  the  arches  and  then 
carefully  turn  the  toes  out  to  the  parallel  position,  holding  the  arches  and 
ankles  in  position,  and  frequently  repeating  the  maneuver.  In  all  cases  it 
is  necessary  to  remember  that  the  ankles  must  be  held  up  over  the  foot,  and 
the  "slump"  of  ankle  and  out  consciously  combated. 

The  prejudice  against  intoeing  of  children  should  be  strongly  combated, 
since  slight  intoeing  is  the  natural  and  strong  position;  and  the  exaggerated 
position  or  pigeon  toe  is  simply  a  natural  effort  to  conserve  arches  and  mus- 
cles not  normal  in  strength." 

Dr.  Harris  supports  Munson's  objections  to  patent  devices  intended  to 
support  the  foot  arch,  upon  the  ground  that  they  relieve  the  symptoms  of 


446         ETIOLOGY    AND    PROPHYLAXIS    OF    OCCUPATIONAL    DISEASES 

discomfort  at  the  expense  of  making  the  underlying  cause  of  the  latter  much 
worse,  for  they  splint  and  restrict  the  use  of  the  very  muscles  upon  the  devel- 
opment and  strengthening  of  which  the  regaining  and  preservation  of  the 
foot  arch  depends. 

Dr.  Jay  W.  Seaver  an  eminent  orthopedist  and  for  many  years  Director 
of  Physical  Culture  at  Yale  considers  Dr.  Harris's  training  suggestions  for 
the  prevention  and  correction  of  this  deformity,  eminently  practical  and  in 
accord  with  the  mechanics  of  the  anatomy  involved. 

Overexercise  of  Certain  Parts  of  the  Body. — The  causes  and  diseases 
due  to  the  excessive  use  of  certain  muscles,  to  eye  strain,  and  excessive  noises 
are  fully  discussed  in  the  chapters  on  Occupational  Neuroses,  and  Diseases 
of  the  Eye  and  Ear.  These  affections  are  of  the  utmost  economic  importance, 
since  they  impair  not  only  the  efl&ciency,  but  also  the  earning  power  of  the 
worker,  and  not  infrequently  compel  a  change  of  work. 

Among  the  affections  due  to  the  overuse  of  the  voice  should  be  mentioned 
chronic  inflammatory  conditions  of  the  pharynx  and  larynx,  in  public  speakers 
(clergymen's  sore-throat),  singers,  train  announcers,  auctioneers,  street 
criers,  etc.  In  some  instances,  laryngeal  spasm  and  paralysis  of  the  vocal 
cords,  with  complete  loss  of  voice,  have  been  recorded. 

Constant  local  pressure,  friction,  and  overuse  of  the  arms  and  hands,  is 
productive  of  much  harm.  This  is  seen  in  the  formation  of  painful  callosities 
in  the  palms  and  fingers,  inflammation  of  the  synovial  lining  of  the  wrist- 
joint  and  tendon  sheaths,  and  enlarged  bursae.  These  conditions  not  in- 
frequently are  followed  by  septic  infections,  such  as  subcutaneous  cellulitis, 
as  seen  in  the  "beat  hand"  and  "beat  elbow"  of  miners.  Cysts  of  the  wrist 
tendons  have  also  been  observed,  in  the  Government  Printing  Office,  in 
persons  engaged  in  making  firm  pressure  with  the  hand  in  folding  heavy 
paper.  Contracture  of  fingers  and  atrophy  of  the  palmar  aponeurosis  are 
also  frequently  observed,  as  a  result  of  hard  manual  labor. 

Occupations  involving  constant  jarring  of  the  entire  body  are  conducive 
to  the  development  of  neurasthenia,  insomnia,  and  gastro-intestinal  neurosis. 

As  an  example  of  overstrain  of  certain  groups  of  muscles  should  be  men- 
tioned the  distended,  yet  flabby  condition  of  the  cheek,  as  observed  in  glass- 
blowers  and  performers  on  wind  instruments.  In  these  cases  there  is  at 
first  a  hypertrophy  of  the  muscular  fibers,  followed  later  by  a  partial  atrophy 
which  not  infrequently  results  in  actual  rupture.  The  air  forced  into  the 
salivary  ducts  causes  dilatation  and  emphysema  of  Steno's  duct,  which  is 
occasionally  followed  by  rupture  and  painful  affections  of  the  parotid  gland. 

Emphysema  of  the  lungs  is  in  some  instances  the  result  of  overstrain 
of  the  pulmonary  tissue,  as  witnessed  by  the  occurrence  of  such  cases  among 
glass-blowers,  users  of  blowpipes,  and  performers  on  wind  instruments. 

Illustrations  of  the  acute  and  chronic  effects  of  excessive  muscular  strain 
are  seen  in  the  undue  prevalence  of  cases  of  hernia,  among  persons  engaged  in 
hard  work,  especially  in  those  who  lift  or  carry  heavy  weights  on  ladders, 


OVERWORK   AND    SPEEDING  447 

as  in  the  building  trades.  Fortunately  derricks  and  lifts  are  diminishing 
these  hazards.  The  effects  of  habitual  hard  work  in  the  causation  of  dis- 
eases of  the  heart  and  circulatory  system,  which  in  some  instances  may  result 
in  sudden  death  from  cardiac  exhaustion  or  rupture  of  the  blood-vessels  have 
been  pointed  out  on  page  239.  Indeed  there  is  ample  statistical  evidence 
to  justify  the  conclusion  that  persons  habitually  engaged  in  hard  work  are 
more  frequently  subject  to  disease  and  accident  and  present  a  higher  mortal- 
ity than  persons  more  favorably  situated. 

Overwork  or  Fatigue.— One  of  the  most  important  predisposing  causes 
to  disease  is  overwork  or  fatigue,  because  the  accumulation  of  waste  prod- 
ucts in  the  blood,  from  muscular  wear  and  tear,  together  with  the  ex- 
pended nervous  energy,  combine  to  render  the  system  more  susceptible  to 
disease.  The  subject  of  fatigue  in  its  physiological  and  pathological  rela- 
tions is  discussed  by  Professor  Lee  in  a  special  chapter. 

From  the  view  point  of  prophylaxis  it  may  be  well  to  bear  in  mind  the 
following  maxims: 

1.  Life  without  daily  purposeful  effort  is  wrong;  there  are  those  who  do 
too  little  work,  and  those  who  do  too  much.  Some  groups  of  muscles  are 
overworked  and  others  are  not  sufficiently  used.  The  brain  worker  lacks 
physical  exercise,  and  the  physical  worker  mental  exercise  and  training 
(Fisher). 

2.  Habitual  hard  work  and  long  hours  are  calculated  to  diminish 
the  general  power  of  resistance  and  to  bring  about  premature  physical 
deterioration. 

3.  The  more  intensive  the  work  ("speeding  up")  and  the  shorter  the 
interval  of  rest  for  the  elimination  of  waste  products,  the  earlier  we  may 
expect  manifestations  of  fatigue. 

4.  Excessive  heat  and  humidity,  exposure  to  vitiated  air  and  toxic  dust 
and  fumes,  violent  concussions  of  the  air,  and  general  jarring  of  the  body, 
constrained  posture,  and  overexertion  of  certain  muscles,  favor  premature 
fatigue. 

5.  Insufficient  or  improper  food,  long  walks  to  work,  vice  and  dissipation 
and  the  abuse  of  alcohol  produce  premature  fatigue. 

6.  Monotonous  work,  employments  involving  mental  strain  and  responsi- 
bihty,  watchful  care  in  machine  work,  fear  about  satisfying  the  "boss," 
anxiety  about  money  and  domestic  affairs  are  all  conducive  to  premature 
fatigue,  while  work  done  with  zest  often  acts  as  a  tonic. 

7^  Night  work  constitutes  a  fatigue  factor  only  when  it  involves  long 
hours  and  loss  of  sleep. 

^'Speeding  Up." — Among  all  the  fatigue  factors,  none  is  more  potent  than 
the  pernicious  practice  of  "speeding  up."  In  order  to  meet  the  demands 
of  competition,  lower  prices,  high  profits,  and  trade  supremacy,  inventive 
genius  is  ever  at  work  to  increase  the  speed  and  output  of  machinery,  and 
employees  have  to  keep  pace  with  the  machine.     This  speeding  up  is  manifest 


448        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

in  all  of  the  mechanical  industries,  especially  in  the  textile  and  clothing  in- 
dustry. Some  of  the  sewing  machines  now  carry  ten  needles  instead  of  one, 
involving  correspondingly  increased  strain  of  the  eyes  to  watch  for  broken 
threads,  and  also  increased  nervous  tension  and  physical  fatigue.  This 
high-pressure  system  had  its  origin  in  this  country  and  is  by  no  means  con- 
fined to  individual  industries.  The  very  excellencies  of  our  progress  have 
stimulated  the  nerves  and  intellect  and  fired  the  ambition  of  men  until  they 
overleap  the  limits  of  their  natural  powers.  Rest  and  recreation  seems  im- 
possible to  many,  and  the  temporary  stimulant  derived  from  the  tempting 
cup  offers,  for  the  time  being,  relief  to  our  physical  and  mental  exhaustion. 
It  is,  however,  like  all  so-called  "nerve  tonics,"  a  dangerous  remedy.  It  is 
like  applying  the  whip  to  a  tired  horse  and  the  result  is  a  constant  increase 
in  the  number  of  prematurely  worn-out  workers,  neurasthenics,  alcohol  and 
drug  habitues. 

Neurasthenia  is  by  no  means  confined  to  mental  workers.  Of  285  cases 
treated  by  Petren,  189  belonged  to  the  laboring  and  agricultural  classes. 
It  is  true  that  certain  occupations  involving  exposure  to  industrial  poisons, 
such  as  coal  gas,  carbon  disulphide,  lead  and  manganese,  predispose  to  this 
disease,  as  do  also  occupations  involving  exposure  to  excessive  heat,  light 
and  noise.  But  when  we  see  an  increase  all  along  the  line  of  industrial 
workers,  affecting,  according  to  Schwab,  about  one-fourth  of  the  garment 
workers  in  St.  Louis,  it  is  evident  that  the  foundation  is  chiefly  laid  in 
the  "speeding  up  system,"  which  has  also  invaded  Europe. 

Preventive  Measures. — The  general  effects  of  overwork  and  chronic 
fatigue  are  characterized  by  loss  of  appetite,  anaemia,  digestive  derangements, 
respiratory  and  cardiac  affections,  fatigue  neuroses,  neurasthenia,  and  gen- 
eral deterioration  of  health. 

In  the  prevention  of  the  far-reaching  consequences  it  is  evident  that  work 
must  be  regulated  by  the  capacity  of  the  individual,  and  hence  it  is  desirable 
at  the  outset  for  persons  to  select  only  employments  for  which  they  are 
physically  fitted.  After  entering  upon  employment  it  is  important  that  all 
the  fatigue  factors  should  be  carefully  considered  and  controlled  by  wise  and 
humane  measures.  So,  for  example,  a  change  of  work  to  less  arduous  tasks 
may  often  prevent  a  complete  breakdown.  It  is  obvious  that  there  must  be 
proper  intervals  for  rest  and  recuperation,  hence  the  necessity  of  regulating 
the  hours  of  labor  and  the  enforcement  of  a  day  of  rest.  We  have  referred 
on  page  viii  to  the  high  mortality  of  the  industrial  workers  of  Great  Britain  at 
the  beginning  of  the  nineteenth  century.  This  was  at  a  time  when  employees 
in  the  cotton  mills  were  obliged  to  work  from  14-18  hours  a  day.  Koelsch 
informs  us  that  after  the  reduction  of  the  hours  of  labor,  from  12-8  hours  a 
day,  in  the  alkali  works  of  Norwich,  the  morbidity  rate  sank  from  10.12 
per  cent,  to  6.1  per  cent.  After  the  introduction  of  the  9-hour  shift  in  the 
English  machine  shops,  in  1872,  the  average  span  of  life  of  these  workers 
was  lengthened  in  the  course  of  17  years  from  38^4  to  48)^  years.     In  esti- 


FEMALE    AND    CHILD    LABOR  449 

mating  the  general  efficiency  of  such  commendable  laws  it  is  but  fair  to  con- 
cede that  the  general  health  movement  in  the  last  four  decades,  especially 
the  improvement  of  the  air  we  breathe  and  the  water  we  drink,  has  played 
an  important  part  in  the  prolongation  of  human  life. 

The  physiological  remedy  for  fatigue  is  rest  and  sleep,  which  offers 
an  opportuity  for  recuperation  (see  sleep,  page  472). 

Hours  of  Labor. — The  enactment  of  laws  limiting  actual  labor  to  8  hours 
a  day  finds  ample  support  in  a  study  of  the  relation  of  fatigue  to  accident 
liability  (see  page  452)  and  can  also  be  defended  upon  general  health  prin- 
ciples. This  is  especially  true  of  females,  who,  on  account  of  their  imperfectly 
developed  muscular  system  and  more  delicate  physique,  require  special 
protection. 

No  child  should  be  permitted  to  work  in  factories  and  wage-earning 
occupations  under  the  age  of  14,  and  then  only  upon  presentation  of  a  medical 
certificate  that  it  is  free  from  physical  defects.  Such  children  should  not 
be  obliged  to  work  longer  than  6  hours,  with  2  hours  of  interval  of  rest  after 
the  first  3  hours.  Under  no  circumstances  should  they  be  permitted  to 
perform  night  work.  The  same  may  be  said  of  individuals  between  the  ages 
of  16  and  18  years,  who,  however,  may  be  permitted  to  work  8  hours  a  day, 
with  proper  intervals  for  meals  and  rest. 

Employment  of  Women  and  Children. — In  the  face  of  many  adverse 
circumstances  under  which  labor  is  often  performed,  it  is  but  natural  that 
the  immature  male  employees  and  females  should  suffer  most.  The  former 
not  infrequently  inherit  a  weak  constitution,  or  acquire  it  by  insanitary 
home  surroundings  and  deficient  food.  Quite  a  number  are  obliged  to 
enter  upon  active  work  long  before  their  bodies  are  sufficiently  developed. 
Apart  from  the  fact  that  child  labor  is  a  menace  to  education,  morals  and 
good  citizenship,  the  effects  of  premature  and  involuntary  labor  upon  the  health 
and  physical  welfare  of  the  child  are  extremely  detrimental.  It  has  been 
shown  that  up  to  the  age  of  13  to  14,  the  muscular  fibers  contain  a  large 
percentage  of  water,  and  in  consequence  are  very  tender  and  weak.  Demet- 
jeff,  cited  by  Rubner,-^  determined  the  lifting  powers  of  the  arm  and  trunk 
of  the  working  class,  and  found  that  the  average  boy  of  14  possesses  about 
one-half  the  muscular  strength  of  an  average  adult  between  35  and  40  years. 

Lifting  Power  of  the  Arm  and  Trunk  of  the  Working  Classes  at  Different  Ages 

Age  Kilograms  Age  Kilograms 

14  years 82  30  to  35  years 150 

16  years loi  35  to  40  years 160 

18  years 128  40  to  50  years 148 

20  to  29  years 140  50  to  60  years 134 

As  a  result  of  imperfect  development  of  muscles  and  bones  it  is  not  surpris- 
ing that  a  large  percentage  of  young  persons  engaged  in  workshops,  factories, 
or  even  at  the  writing  desk,  develop  lateral  curvature  of  the  spine  and  other 
29 


450        ETIOLOGY    AND    PROPHYLAXIS    OF    OCCUPATIONAL    DISEASES 

deformities,  such  as  flat-foot,  knock-knee,  in-knee,  etc.,'  not  to  mention 
general  weakness,  and  a  predisposition  to  other  diseases.  All  of  the  bad 
effects  are  naturally  intensified  by  insanitary  environments,  especially  when 
the  occupation  involves  exposure  to  dust  and  fumes.  In  quite  a  number 
of  European  countries  minors  are  excluded  from  trades  involving  exposure  to 
industrial  poisons.  During  the  last  Census  there  were  1,752,187  children 
under  16  years  of  age  engaged  in  gainful  occupations;  of  these  over  80,000 
were  employed  in  the  textile  industry;  about  25,000  in  mines  and  quarries; 
12,000  in  the  manufacture  of  tobacco  and  cigars;  over  10,000  in  wood  in- 
dustries; 71 16  in  the  glass  industry;  over  7000,  mostly  girls,  in  laundries; 
2000  in  bakeries;  138,000  as  waiters  and  servants;  42,000  boys  as  messengers; 
and  20,000  boys  and  girls  in  stores. 

According  to  Koelsch^^  women  possess  only  from  six-tenths  to  seven-tenths 
the  strength  of  men  of  like  weight,  and  yet,  in  the  struggle  for  existence, 
quite  a  number  enter  the  ranks  of  industrial  workers.  For  physiological 
reasons  they  are  quite  sensitive  to  the  effects  of  physical  and  mental  fatigue, 
and  it  is  perhaps  fortunate  that,  because  of  marriage  or  inability  to  with- 
stand the  strain  of  modern  industries,  the  majority  abandon  their  strenuous 
work  before  permanent  injury  is  done.  But  even  as  it  is.  Roth  tells  us  that 
75  per  cent,  of  145  female  inmates  in  a  German  sanitorium  suffered  from  anae- 
mia, chlorosis  and  neurasthenia,  as  a  result  of  overwork.  It  is  a  matter  of 
common  observation  that  women  who  have  had  to  deny  themselves  proper 
rest  and  care  during  the  menstrual  period,  for  several  weeks  before  and  after 
confinement,  are  very  liable  to  suffer  from  chronic  uterine  diseases  and  hemor- 
rhages, while  miscarriages  and  premature  births  are  not  infrequent  results 
of  overwork.  Statistics  collected  by  Neisser  indicate  that  such  accidents 
are  quite  common  among  farmers'  wives,  laundresses,  seamstresses  and 
women  employed  in  the  jewelry  industry,  where  foot  presses  are  used. 

The  value  of  proper  care  and  rest  during  pregnancy  is  shown  by  the 
Leipsic  statistics,  which  indicate  that  the  percentage  of  premature  births 
was  0.3  and  of  abortions  2.3  among  the  volunteer  insured,  against  1.7  and 
15.5  per  cent,  among  the  compulsory  insured.  This  difference,  Koelsch^^ 
explains,  is  due  to  the  fact  that  the  volunteer  insured  mother  pays  the  cost 
of  insurance  and  sacrifices  more  or  less  of  her  wage,  in  order  to  protect  her 
offspring.  The  percentage  is  especially  high  among  workers  exposed  to  lead 
poisoning:  53.6  per  cent,  in  metal  polishers,  22.9  per  cent,  in  type  foundry 
workers,  30  per  cent,  among  the  tin-foil  capsule  workers  of  Vienna. 

Rubner,  cited  by  Koelsch,  estimates  the  number  of  still-births  in  certain 
harmful  occupations  as  between  150  and  170,  against  an  average  rate  of 
7,7,  per  1000  births. 

Strassmann's  and  Falk's  statistics  show  an  undue  prevalence  of  menstrual 
disorders,  inflammatory  conditions  and  displacement  of  the  uterus,  abortions 
and  diseases  of  pregnancy  among  seamstresses  using  foot-power  sewing 
machines.     This  excess,  amounting  to  between  40  and  50  per  cent.,  is  at- 


ACCIDENTS    AND    INJURIES  45 1 

tributable  to  prolonged  sedentary  and  faulty  positions,  constipation,  chloro- 
sis, pelvic  congestions,  and  possibly  also  active  hyperaemia  of  the  pelvic 
organs  caused  by  overexertion  of  the  lower  extremities,  since  the  difference 
is  not  so  pronounced  in  hand  seamstresses  and  those  using  power  machines. 
Similar  conditions  are  observed  among  laundresses,  who  moreover  not  infre- 
quently suffer  from  varicose  veins  and  ulcers  of  the  leg. 

Space  will  not  permit  of  a  more  detailed  presentation  of  the  statistics  so 
laboriously  collected  by  Koelsch.-*  A  few  important  facts  may  be  summarized 
as  follows:  i.  The  Austrian  and  Leipsic  statistics  indicate  that  the  mortality 
rates  of  female  workers  between  the  ages  of  15  and  60  are  distinctively  higher 
than  in  unoccupied  females  of  the  same  age  period.  2.  The  Leipsic  statistics 
show  that,  while  the  death  rate  is  about  equal  for  both  sexes  below  the  age 
of  15,  between  the  ages  of  24  and  29  it  is  1.09  per  1000  higher  in  the  female 
workers,  and  between  30  and  40  it  is  0.70  per  1000  higher  than  in  the  male 
workers.  3.  The  morbidity  rates  and  duration  of  illness  are  likewise  con- 
siderably higher  during  the  same  age  period  than  in  male  workers.  The 
number  of  cases  of  sickness  per  100  for  female  workers  was  41,8  with  an 
average  duration  of  24.6  days,  while  the  rate  for  male  workers  was  39.6  and 
21.6  respectively.  After  the  completion  of  the  menopause,  statistics  are  in 
favor  of  female  workers.  4.  Diseases  of  the  blood,  of  the  nervous  system 
and  of  the  digestive  organs  predominate  in  all  comparative  statistics.  Tuber- 
culosis is  less  frequent  among  female  workers,  19.2  per  10,000  against  23.2 
in  the  males.  During  the  child-bearing  period,  however,  the  rates  are  ex- 
cessive, especially  during  the  ages  of  30  to  35  years.  This  difference  is  less 
pronounced  in  the  general  population  and  indicates  that  industrial  work 
combined  with  maternal  functions  is  harmful. 

Accidents  and  Injuries. — The  total  number  of  deaths  reported  from 
accidents  during  the  last  census  year  was  57,513,  of  which  43,414  were  males 
and  14,099  females,  and  the  proportion  of  deaths  from  these  causes  in  1000 
deaths  from  all  known  causes  was  57.6.  In  1890  the  corresponding  propor- 
tion was  53.7.  In  the  registration  area  the  rate  was  96  per  100,000  of  popu- 
lation. In  1890  the  rate  was  91.9.  The  rate  in  the  cities  was  somewhat 
higher  than  in  the  rural  districts,  and  the  rate  for  males  was  about  three 
times  as  high  (125.4)  as  among  females  (42.2).  This  is  due  to  the  more 
sheltered  position  of  females  and  because  males  alone  are  generally  engaged 
in  the  more  dangerous  operations. 

The  highest  death  rates  from  accidents  occur  in  persons  45  years  of  age 
and  over,  and  the  lowest  in  children  under  the  age  of  15,  which  indicates 
that  employment  in  factories,  workshops,  mines,  steel  industries,  the  railway 
service,  etc.,  influences  to  a  great  extent  the  number  of  accidents  and  injuries. 

Life  insurance  and  accident  policy  statistics  plainly  indicate  the  danger 
of  occupations  which  involve  contact  with  machinery.  This  is  generally 
attributed  to  individual  carelessness  or  the  negligence  of  others.  It  would 
be  interesting  to  know  just  how  much  of  this  so-called  carelessness  is  really 


452         ETIOLOGY    AND    PROPHYLAXIS    OF    OCCUPATIONAL    DISEASES 

due  to  fatigue,  which  doubtless  lowers  the  power  of  alertness.  Not  infre- 
quently accidents  from  boiler  explosions,  circular  saws,  planes,  belting  and 
flying  fragments  are  due  to  a  lack  of  proper  safety  devices.  As  might  be 
expected,  many  of  the  accidents  befall  children  and  inexperienced  persons, 
and  take  place  at  night  or  in  badly  lighted  establishments.  The  German 
accident  statistics,  cited  by  Roth,^^  clearly  indicate  that  accidents  increase 
with  mental  and  physical  fatigue.  Upon  the  assumption  that  there  is  one 
accident  for  every  three  working  hours  during  the  year,  the  average  number 
of  industrial  accidents  was  as  follows: 

6- 9  A.M i.io  12-3  P. M 1.02 

9-12  A.M.. 2.26  3-6  P. M 2.  II 

S?iturdays,  3-6  P.M 2 .  76 

Prof.  Imbert  at  the  International  Congress  on  Hygiene  at  Brussels,  1903, 
presented  similar  statistical  material.  According  to  Rubner,^^  of  100  acci- 
dents 41  befell  children  under  15  years  of  age,  36.4  befell  persons  between  15 
and  25  years,  13.1  befell  persons  between  25  and  40,  and  9.5  befell  persons 
between  40  and  60  years  of  age.  The  upper  extremities  were  involved  in  87 
per  cent,  of  the  cases,  the  lower  extremities  in  7.5  per  cent.,  and  the  head  and 
trunk  in  5.5  per  cent. 

Swiss  statistics  show  that  among  1000  workers  accidents  occur  as  follows: 
Cotton  spinners  22.2,  millers  28.0,  paper  industry  31.1,  carpenters  35.2, 
locksmiths  46.9,  brewers  66.7,  masons  80.5,  blacksmiths  93.1,  metal  workers 
102. 1,  moulders  132.2. 

Many  of  the  accidents  befall  the  eye.  Magnus  attributes  8.5  per  cent, 
of  all  cases  of  blindness  to  accidents.  Interesting  details  will  be  found  under 
various  occupations.  The  number  of  accidents  in  textile  mills  in  this  coun- 
try, considering  the  large  number  of  fast-running  machines,  is  not  large, 
during  a  period  of  almost  5  years  at  the  Pacific  Mills,  Lawrence,  Mass.,  with 
about  52,000  employees  amounting  to  1000.  Of  these,  one  was  killed  out- 
right, one  fatally  injured,  86  seriously  injured  (broken  limbs  or  amputations 
necessary),  910  slightly  injured,  and  two  suffered  from  nervous  shock  but 
were  physically  uninjured.  The  underlying  cause  of  injury  is  given  as 
follows:  Careless  manipulation  539,  inattention  to  surroundings  177,  taking 
chances  of  being  injured — deliberate  carelessness,  such  as  cleaning  machinery 
while  running,  etc.,  164,  carelessness  of  fellow- workmen  51,  unforeseen  liability 
60,  unclassified  9. 

Prevention  of  Accidents. — Most  of  the  States  have  taken  steps  to  reduce 
accidents  to  a  minimum.  For  this  purpose  they  have  enacted  laws  concern- 
ing employers'  liability  if  they  fail  to  provide  safety  devices  for  the  movable 
and  dangerous  parts  of  machinery.  Much  has  been  done  also  in  the  preven- 
tion of  accidents  in  mines,  in  the  railway  service,  in  steel  plants,  etc.,  which 
will  be  referred  to  under  specific  occupations. 


WELFARE    MEASURES    FOR    WAGE    EARNERS  453 

A  careful  inspection  of  steam  boilers  and  examination  of  engines  has 
materially  lessened  the  dangers  from  boiler  explosions,  so  that  in  England 
there  is  only  about  one  explosion  in  6200  registered  boilers.  Nearly  all 
states  require  some  form  of  protection  in  case  of  fire,  by  means  of  fire  escapes, 
semi-fireproof  buildings,  and  doors  swinging  outwardly,  while  a  respectable 
number  also  provide  for  automatic  sprinklers  and  other  fire-extinguishing 
methods.  For  suitable  clothing  see  page  442.  For  preventive  legislation 
see  page  801. 

General  Welfare  Measures  for  Wage  Earners.— Sufl5cient  evidence  has 
been  adduced  and  more  will  be  presented  in  subsequent  pages  to  indicate 
that  the  laboring  classes  need  special  protection  against  the  many  occupa- 
tional hazards  and  injurious  environments  to  which  they  are  exposed.  This 
protection  should  emanate  from  the  State,  the  employers,  the  community 
and  the  employees  themselves.  Each  has  certain  duties  and  responsibilities, 
and  for  success  coordination  and  cooperation  are  essential.  The  protection 
of  wage  earners  should  extend  to  the  work  and  workshop,  and  in  case  the 
employees  are  housed  by  the  employer  also  to  the  living  and  sleeping  quar- 
ters, mess  rooms,  etc. 

A  sanitary  workshop,  apart  from  good  management,  demands  sufficient 
air-space  for  each  inmate,  a  suitable  temperature,  proper  ventilation,  general 
cleanliness,  sanitary  conveniences,  separate  toilet  rooms  for  men  and  women, 
facilities  for  personal  cleanliness,  wash  rooms,  shower  baths,  dressing-rooms, 
clothes  lockers,  lunch  rooms,  etc. ,  and  the  State  should  see  to  it  that  the  general 
principles  presented  in  this  book  are  embodied  in  effective  laws.  A  few 
States  make  provisions  for  "fresh  drinking  water  of  good  quality"  and  indi- 
vidual drinking  cups  or  drinking  fountains.  Some  of  the  States  regulate 
the  spitting  habit  by  insisting  upon  proper  cuspidors. 

Tenement  Factories. — Among  the  most  dangerous  forms  of  workshops  is 
one  class  which  most  state  laws  entirely  ignore.  For  example,  under  the 
laws  of  the  State  of  New  York,  relating  to  manufacturing  in  tenement  houses, 
according  to  Dr.  Anna  S.  Daniels,  33  distinct  industries  may  be  carried  on  in 
the  living  rooms  of  the  workers,  because  they  involve  hand-work  or  simple 
machinery.  There  are  over  23,000  licensed  home  factories  in  the  city  of  New 
York  alone.  In  addition  to  wearing  apparel  for  men,  women  and  children, 
including  adornment  of  woman's  dress,  the  flowers  and  feathers  for  her  dress, 
the  hats  themselves  and  neck  wear  of  every  description,  Dr.  Daniels  found 
the  manufacture  of  paper  boxes,  cigars,  pocketbooks,  jewelry,  clocks, 
watches,  wigs,  fur  garments,  paper  bags,  etc.  The  articles  are  not  infre- 
quently handled  and  stored  in  infected  rooms.  Of  150  families  tabulated 
by  her,  66  continued  at  work  during  the  entire  course  of  the  contagious  dis- 
ease, such  as  tuberculosis,  measles,  scarlet  fever,  diphtheria,  etc.,  for  which 
she  was  attending  the  family. 

Apart  from  the  occupations  referred  to,  numerous  bakeries,  candy,  ice- 
cream, milk  and  butcher  shops,  bottling  establishments,  tailor,  cobbler  and 


454         ETIOLOGY    AND    PROPHYL.\XIS    OF    OCCUPATIONAL    DISEASES 

Other  repair  shops  are  carried  on  in  basements  under  the  most  insanitary 
environments. 

Construction  Camps. — It  not  infrequently  happens  that  mining,  lumber, 
construction  companies,  and  other  large  concerns  provide  board  and  lodging 
for  their  unmarried  employees.  Again,  in  a  number  of  the  smaller  industries, 
the  employees  not  infrequently  board  with  the  family  and  are  obliged  to 
sleep  in  objectionable  rooms. 

The  baneful  effects  of  overcrowding  as  observed  in  the  construction 
camps  at  Panama  have  been  referred  to  on  page  43 1 .  All  remedial  provisions 
should  come  up  to  a  reasonable  standard  as  regards  salubrity.  Factory 
sanitation  and  the  matters  just  alluded  to  are  after  all  largely  questions  of 
public  health  and  should  not  be  left  to  the  discretion  of  the  individual  em- 
ployer, but  the  principles  which  ought  to  be  adopted  should  be  embodied 
in  suitable  laws  and  enforced  by  competent  inspectors. 

What  the  Federal  Government  May  Do. — Much  excellent  work  has 
been  and  is  being  done  by  the  United  States  Bureau  of  Labor,  in  the  collection 
and  publication  of  facts  concerning  every  phase  of  industrial  and  social  better- 
ment. The  bulletins  issued,  if  carefully  read,  cannot  fail  to  exert  a  tremen- 
dous educational  influence  upon  those  for  whom  they  are  primarily  intended, 
viz.,  the  wage  earners  and  employers.  But,  while  much  has  been  achieved, 
more  remains  to  be  accomplished.  It  has  been  suggested  that  apart  from 
establishing,  in  connection  with  the  National  Museum,  a  permanent  exposi- 
tion relating  to  industrial  betterment  of  wage  earners,  it  is  clearly  the  duty 
of  the  Federal  Government  to  establish  and  adopt  a  standard  of  industrial 
hygiene  for  all  the  government  workshops. 

President  Roosevelt,  in  a  message  to  Congress,  Dec,  1907,  has  said 
"  the  National  Government  should  be  a  model  employer.  It  should  demand 
the  highest  quality  of  service  from  each  of  its  employees,  and  it  should  care 
for  all  of  them  properly  in  return " 

We  regret  to  say  that,  with  the  possible  exception  of  the  extraordinary 
precautions  exercised  to  protect  the  health  of  the  employees  in  the  operations 
connected  with  the  construction  of  the  canal  on  the  Isthmus  of  Panama,  the 
sanitation  of  oflaces  and  workshops  for  Government  employees  is  not  even 
on  a  par  with  some  of  the  best  private  industrial  concerns  of  this  country. 
There  can  be  no  question  that  model  government  workshops,  and  efforts 
for  the  promotion  of  the  general  welfare  of  the  employees,  would  prove  a 
salutary  precept  and  example.  The  General  Government  is  not  in  a  position 
to  legislate  for  the  States,  but  it  can  at  least  enact  a  model  labor  and  factory 
law  for  the  District  of  Columbia  and  all  of  the  workshops  connected  with 
the  Army  and  Navy  arsenals — gun  factories,  powder  depots,  and  clothing 
depots — and  for  the  immense  army  employed  on  the  Isthmus  of  Panama. 

Industrial  Insurance. — Apart  from  strictly  sanitary  measures  for  the 
promotion  and  preservation  of  health,  the  Government,  as  a  model  employer, 
should  provide  some  adequate  relief  in  case  of  sickness,  accidents,  or  dis- 


INDUSTRIAL    INSURANCE  455 

ability  from  disease  or  injuries  contracted  in  the  line  of  duty,  and  thus 
initiate  a  system  which  has  proved  to  be  a  vertitable  blessing  elsewhere. 
Under  the  operation  of  the  German  law,  enacted  in  1883,  all  workmen  em- 
ployed in  commerce,  industries  and  the  handicrafts,  whose  income  is  less 
than  2000  marks  (about  $480),  must  be  insured.  By  special  regulation  this 
requirement  may  be  extended  to  agricultural  and  household  employees. 
To  secure  the  enrollment  of  individuals  for  "sick  benefits,"  the  employers, 
in  the  industries  subject  to  the  law,  are  required  to  send  to  the  proper  in- 
surance fund  the  name  of  each  person  who  enters  or  leaves  their  service. 
The  income  of  the  sick  fund  is  partly  derived  from  the  dues  of  members. 
The  amount  is  fixed  by  each  local  association,  but  cannot  exceed  6  per  cent, 
of  the  member's  wages.  The  employee  pays  two-thirds  of  the  dues  and  the 
employer  one-third.  The  employee's  share  is  deducted  from  his  wages 
and  paid  directly  to  the  insurance  fund  by  the  employer,  when  he  remits 
his  own  share. 

A  detailed  account  of  the  operations  of  this  system  will  be  found  in  my 
report  as  Chairman  of  the  Committee  on  Social  Betterment  of  the  President's 
Homes  Commission,  1908,  page  87,  from  which  the  following  synopsis  of 
practical  results  is  here  reproduced. 

1.  At  the  end  of  1905,  in  all  70,000,000  pensioners  (sick,  injured, 
invalids  and  their  dependents)  had  received  $1,200,000,000  in  benefits. 
The  workmen  have  contributed  less  than  one-half  of  the  premiums  and  have 
received  $480,000,000,  more  than  they  paid  out.  Property  is  owned  to  the 
amount  of  $408,000,000,  of  which  $120,000,000  has  been  invested  in  work- 
men's dwellings,  hospitals  and  convalescents'  homes,  sanitoria,  baths  and 
similar  institutions  of  welfare. ^'^ 

2.  The  financial  status  of  the  workingmen  has  been  improved  at 
least  to  the  extent  of  the  benefits  received  from  the  amounts  contributed 
by  the  employers  and  the  Government.  Experience  has  shown  that  em- 
ployers have  not  deducted  their  share  of  the  dues  from  wages. 

3.  The  hygienic  conditions  of  the  workingmen  have  been  improved, 
both  on  account  of  the  safeguards  which  the  accidental  insurance  organiza- 
tions require  employers  to  use  and  because  of  the  special  efforts  made  by 
the  "sick  funds"  to  reduce  the  sick  rate  among  the  members  to  a  minimum. 
The  general  knowledge  in  regard  to  the  preservation  and  promotion  of  health, 
which  the  "sick  fund  organization"  has  disseminated  by  means  of  circulars, 
monographs,  popular  lectures,  etc.,  has  exerted  a  tremendous  educational 
influence  in  the  promotion  of  heath  and  morals. 

One  of  the  most  beneficient  features  of  the  entire  system  has  been  that 
parts  of  the  funds  of  these  organizations  are  invested  in  model  houses  for 
wage  earners,  and  hospitals  and  sanitaria  for  the  use  of  members.  It  is 
interesting  to  note  that  the  Prussian  "insurance  institute  and  sick  funds" 
in  1907  alone  maintained  28  hospitals  and  sanitaria,  the  latter  chiefly  for 
consumptives  and  convalescents.     One  of  the  latest  features  was  the  estab- 


456        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

lishment  at  Lichtenberg,  near  Berlin,  of  a  special  hospital  for  sexual  diseases 
in  the  male,  and  a  sanitarium  for  nervous  and  anaemic  female  wage  earners 
in  Pyrmont  (Hannover),  all  upon  the  principle  that  it  is  in  the  highest 
degree  good  economy  to  restore  as  speedily  as  possible  the  unproductive 
to  the  ranks  of  the  producers. 

The  writer  has  purposely  devoted  much  space  to  the  German  Industrial 
Insurance  system,  because  he  realizes  that  sickness  and  funerals  are  the 
most  potent  causes  of  poverty  and  distress,  and  that  worry  and  anxiety 
often  retard  convalescence.  He  knows,  from  personal  knowledge,  that 
prior  to  1883  Germany  depended  upon  employers'  liability  laws,  charitable 
organizations,  and  private  companies  for  the  protection  of  her  wage  earners, 
with  very  questionable  results.  While  much  has  been  achieved  in  other 
directions  for  the  prevention  of  disease,  the  most  distinct  gain  in  social 
political  endeavors  was  made  by  the  enactment  of  these  laws,  and  especially 
the  law  of  June,  1889,  authorizing  "insurance  institutes"  to  invest  part  of 
their  funds  in  hospitals  and  sanitaria,  thus  affording  the  best  possible  facilities 
for  speedy  recovery,  and  the  prevention  as  far  as  practicable  of  permanent 
disability. 

"What  the  Employer  May  Do. — Social  betterment  cannot  be  disas- 
sociated from  industrial  betterment,  and  it  is  here  that  the  employer  can  do 
much  for  the  welfare  of  his  employees.  Apart  from  a  cheerful  compliance 
with  the  laws  and  ordinances  which  may,  from  time  to  time,  be  enacted  for 
the  protection  of  the  working  classes,  it  is  clearly  the  duty  of  the  employer 
to  promote  in  every  way  the  efficiency  and  earning  power  of  the  wage 
earner,  and  to  pay  such  wages  as  are  necessary  to  improve  the  standard  of 
living  among  poorly  paid  employees. 

In  occupations  involving  exposure  to  industrial  poisons  it  is  a  doubtful 
policy  to  employ  casual  labor  or  to  attempt  the  instruction  of  new  laborers. 
It  has  been  shown  over  and  over  again  that  accidents  and  cases  of  industrial 
poisoning  are  less  liable  to  occur  in  experienced  workers.  Hence  it  is  far 
better  to  take  precautionary  measures  in  the  first  place,  and  in  case  of  an 
impending  breakdown  to  consider  the  question  of  "change  of  work  instead 
of  change  of  workers." 

There  is  no  doubt  that  thoughtful  employers  generally  realize  that  they 
are  not  only  responsible  for  the  proper  technical  training  of  apprentices  but 
also  for  their  habits,  and  a  gratifying  number  of  establishments  have  made 
efforts  to  surround  them  with  opportunities  for  mental,  moral  and  physical 
improvement.  There  is  a  class  of  youthful  employees,  both  males  and 
females,  for  whom  the  writer  begs  to  enter  a  special  plea;  they  are  entitled 
to  every  consideration,  because,  either  as  a  result  of  inheritance  or  faulty 
environments,  they  have  acquired  a  general  inaptitude;  they  are  perfectly 
willing  to  work,  but  awkward  in  all  their  movements — simply  do  not  know 
how  to  work — and  special  pains  should  be  taken  to  teach  them  by  patient 
fellow-workmen. 


INDUSTRIAL   BETTERMENT  457 

Industrial  Betterment. — -Space  will  not  permit  to  enter  into  details  con- 
cerning efforts  which  have  been  made  by  employers  at  home  and  abroad 
in  the  promotion  of  the  general  welfare  of  the  working  classes.  Every  effort 
in  the  right  direction  results  in  the  health  and  efficiency  of  employees  being 
promoted,  the  profits  of  the  manufacturer  increased  and  the  quality  of  the 
products  improved. 

Among  the  most  important  betterments  may  be  mentioned:  (i)  the  in- 
creasing of  industrial  efficiency,  through  industrial  schools  and  manual 
training  classes;  (2)  the  care  for  employees'  health  and  comfort  by  means 
of  bathing  facilities,  gymnasiums,  calisthenics,  base  ball,  bicycle  clubs, 
dining  and  lunch  rooms,  and  the  furnishing  of  hot  lunches,  free  or  at  cost — 
some  establishments  even  permit  dancing  during  the  noon  hour — improved 
sanitary  conditions  and  appliances,  lectures  and  demonstrations,  medical 
supervision;  (3)  the  improvement  of  domestic  conditions  by  means  of  im- 
proved dwellings,  instruction  in  sewing,  cooking  and  housekeeping,  in  land- 
scape and  kitchen  gardening,  and  in  exterior  and  interior  decorations  of 
homes;  (4)  the  care  of  sick  and  disabled  employees  by  means  of  rest  rooms, 
emergency  rooms,  first-aid  outfits,  medical  attendance  and  hospital  facilities, 
free  insurance,  and  by  the  encouragement  of  beneficial  organizations;  (5) 
club  organizations  for  social,  recreative  and  intellectual  purposes,  by  means 
of  free  lecturers,  libraries,  kindergartens  and  educational  classes,  social 
gatherings,  summer  outings,  meeting  places,  game  rooms,  banquets,  dances, 
etc.;  (6)  the  encouragement  of  musical  and  dramatic  clubs  and  the  promotion 
of  spiritual  life  by  means  of  Sunday  schools  and  general  religious  work;  (7) 
the  cultivation  of  thrift  through  savings  bank  facilities,  building  associations 
or  provident  organizations,  rewards  for  valuable  suggestions  of  employees, 
for  faithful  service,  or  the  manifestation  of  zeal  and  interest  in  their  employ- 
ment; (8)  the  promotion  of  employees'  personal  interest  in  the  successful 
conduct  of  the  business  by  encouraging  and  assisting  them  to  purchase  shares, 
financial  aid  to  employees  in  case  of  unusual  hardships  and  distress,  and  the 
cultivation  of  cordial  and  even  confidential  relations  between  employer  and 
employee. 

What  the  Public  May  Do. — It  will  be  conceded  that  the  burdens  of  im- 
proving industrial  and  social  conditions  should  not  be  carried  by  the  em- 
ployers and  employees  alone.  There  are  many  phases  of  importance,  from 
the  standpoint  of  public  health  and  humanity,  which  should  concern  every 
thoughtful  man  and  woman.  Reference  has  already  been  made  to  the  dan- 
gerous conditions  under  which  many  of  the  trades  and  occupations  are 
carried  on  in  tenement  houses.  While  this  is  in  part  due  to  the  greed  of  the 
manufacturer,  because  it  means  less  factory  space,  less  rent,  light,  fuel,  and 
a  decidedly  smaller  pay-roll,  the  consumer  is  equally  to  blame  because  of 
his  constant  demand  for  cheaper  goods,  quite  oblivious  to  the  fact  that  the 
garments  may  be  a  source  of  danger  from  infectious  diseases,  and  are  stained 
with  the  sweat  and  blood  of  helpless  women  and  children. 


458         ETIOLOGY    AND    PROPHYLAXIS    OF    OCCUPATIONAL    DISEASES 

During  one  of  the  Presidential  campaigns  a  clever  orator  referred  to 
Glasgow,  and  told  us  that  41,000  of  the  100,000  laboring  families  of  that 
manufacturing  center  lived  in  one-room  tenements,  and  that  this  one  room 
for  a  family  of  father,  mother,  daughter  and  sons  told  what  the  wages  in 
Scotland  were  and  how  they  dragged  humanity  down  into  bestiality  and 
misery.  It  must  be  confessed  that  similar  conditioiis  obtain  in  nearly  every 
American  industrial  city.  The  effects  of  such  living  conditions  upon  death 
rates  will  be  presently  referred  to.  In  the  meantime,  it  will  be  readily  con- 
ceded that  the  people  do  not  as  a  rule  live  in  such  quarters  from  choice,  but 
from  sheer  necessity.  Low  wages  not  only  compel  the  working  classes  to 
find  shelter  in  houses  unfit  for  human  occupation,  but  also  affect  their  health 
and  the  health  of  their  children  by  insufficient  food  and  clothing;  and,  last 
but  not  least,  it  means  the  utilization  of  child  and  female  labor. 

It  is  to  be  hoped  that  public  conscience  may  be  sufficiently  aroused  to 
insist  upon  adequate  wages  for  all  classes,  and  that  the  producer  and  consumer 
alike  will  be  willing  to  assume  this  responsibility,  not  as  a  matter  of  charity, 
but  in  justice  to  the  laboring  classes. 

Houses  for  Wage  Earners. — In  the  whole  range  of  social  betterment  and 
sanitation,  especially  in  our  efforts  to  combat  tuberculosis,  no  field  affords 
better  opportunity  for  philanthropic  work  than  the  erection  of  sanitary 
homes  for  wage  earners,  at  reasonable  rentals,  the  encouragement  of  cooking 
schools  and  the  establishment  of  model  lodging  and  eating  houses.  The 
Washington  Housing  Companies  have  an  investment  of  over  $1,000,000, 
have  paid  5  per  cent,  annual  dividends,  from  the  very  inception  of  the  com- 
pany, and  have  a  surplus  fund  of  over  $225,000.  London  has  more  than 
$100,000,000  invested  in  model  tenements. 

The  housing  of  the  working  classes  has  very  properly  been  made  the  sub- 
ject of  legislation  in  many  countries,  and  is  a  matter  in  which  factory  owners, 
labor  unions,  and  the  general  public,  should  be  deeply  and  mutually  interested. 
There  are  several  systems  of  dwellings  for  artisans  and  laborers,  viz.,  indi- 
vidual houses  or  cottages,  rows  of  houses  under  one  roof,  and  the  so-called 
"flat."  Preference  should  be  given,  when  practicable,  to  the  cottage  sys- 
tem, but  in  large  cities,  unfortunately,  the  value  of  real  estate  frequently 
compels  the  erection  of  large  tenements.  In  such  an  event  the  State  should 
insist  upon  hygienic  requirements  as  regards  air-space,  light  and  ventilation. 
No  home  can  be  considered  sanitary  where  one  room  has  to  answer  the  pur- 
poses of  living  room,  sleeping  room  and  kitchen,  or  where  the  water-closet 
or  privy  is  used  by  more  than  one  family. 

With  the  present  rapid  transit  facilities,  in  every  city,  our  voice  should 
be  clearly  in  favor  of  individual  homes;  and  when  this  is  impracticable,  we 
should  insist  upon  broad  streets  and  deep  yards.  No  more  than  68  per  cent, 
of  the  lot  should  be  covered  by  the  house,  and  the  height  of  the  building 
should  never  exceed  the  width  of  the  street.  The  baneful  effects  of  tene- 
ment houses  should  be  avoided,  as  infectious  diseases  are  more  liable  to 


HOUSING    OF    WAGE    EARNERS  459 

spread,  in  consequence  of  aerial  infection  and  a  more  intimate  contact  of 

I  the  occupants. 

I       Apart  from  structural  defects,  there  is  no  doubt  that  the  death  rate  is 

'largely  determined  by  the  number  of  occupants  to  a  room.  Russell  has 
shown  that  in  Glasgow,  when  the  average  number  of  persons  to  each  room 
was  only  1.31,  the  mortality  was  21.7  per  1000,  and  when  the  number  of 

1  occupants  amounted  to  2.05  for  each  room,  the  mortality  reached  28.6  per 

!  1000. 

The  death  rate  at  Berlin,  in  1885,  among  the  73,000  one-room  tenements 

I  was  16.35  P^^  1000,  against  5.4  per  1000  among  308,000  residents  occupying 
four  or  more  room  apartments.^^  Neumann,^*  in  investigating  271 1  infan- 
tile deaths  in  Berlin,  found  that  1792  occurred  in  one-room  apartments, 
754  in  two-room  apartments,  122  in  three-room  apartments,  and  43  in  apart- 
ments of  four  rooms  and  over. 

Insanitary  dwellings  are  to  be  found  everywhere,  particularly  in  older 
cities  erected  at  a  time  when  the  principles  of  sanitation  were  comparatively 
unknown.  One  of  the  most  important  municipal  problems  is  to  correct 
existing  evils  by  the  enactment  and  enforcement  of  suitable  laws.  It  re- 
quires, however,  a  strong  pubHc  sentiment  to  bring  about  a  complete  and 
satisfactory  reformation,  as  evidenced  by  the  housing  movement  everywhere. 
The  housing  conditions  of  the  least  resourceful  people  have  been,  and 
are  even  now,  more  potent  than  any  other  factor  in  helping  to  swell  the  fright- 
ful mortality  from  consumption  and  other  so-called  house  diseases  engen- 
dered by  unwholesome  environments.  The  existence  of  disease-breeding 
habitations  is  a  reflection  upon  Christian  civilization,  and  there  should  be 
suflScient  human  sympathy  to  provide  decent,  healthful  homes  for  our  wage 
earners,  who  constitute,  after  all,  the  bone  and  sinew  of  the  country.  This  is 
one  of  the  occasions  when  we  may  well  act  as  our  brother's  keeper. 

The  history  of  improved  dwellings  reveals  everywhere  a  lessened  death 
rate,  and  the  experience  of  the  Washington  Sanitary  Improvement  Company 
is  equally  gratifying.  During  the  year  ending  December  31,  1906,  the  apart- 
ments were  occupied  by  778  adults  and  380  children,  total  11 58;  births,  39, 
and  only  16  deaths,  10  adults  and  6  infants;  a  death  rate  of  about  13.7  per 
1000,  which,  with  all  due  allowance  for  the  average  age  of  the  occupants, 
shows  a  remarkably  low  mortality,  when  compared  with  the  general  death 
rate  among  the  white  population  of  15.16  per  looo. 

The  regeneration  of  the  housing  conditions  for  the  least  resourceful 
people  is  the  great  sanitary  and  social  problem  of  the  twentieth  century. 
Take  away  the  hovels  and  filthy  places,  let  sunshine  and  pure  air  circulate 
through  the  homes,  and  teach  them  habits  of  cleanliness  and  responsibility, 
and  the  first  step  toward  the  elevation  of  the  degraded  and  the  education  of 
the  ignorant  will  be  taken,  not  only  in  the  warfare  against  tuberculosis  and 
other  diseases  engendered  by  insanitary  surroundings,  but  also  in  the  battle 
for  a  higher  moral  and  social  standard. 


460        ETIOLOGY    AND    PROPHYLAXIS    OF    OCCUPATIONAL    DISEASES 

Lodging  Houses  or  Homes  for  Wage  Earners —Those  who  have  read  "The 
Long  Day"  cannot  fail  to  be  impressed  with  the  just  criticism  of  our  present 
system  of  homes  for  working  girls.  The  author  makes  a  strong  plea  for 
homes  designed  after  the  Mills  Hotels  for  working  men;  no  charity,  but  so 
built  and  conducted  that  they  will  pay  a  4  per  cent,  rate  of  interest  upon  the 
money  invested.  ''A  clean  room  and  three  wholesomely  cooked  meals  a 
day  can  be  furnished  to  working  girls,  at  a  price  such  as  would  make  it  possi- 
ble for  them  to  live  honestly  on  the  small  wages  of  the  factory  or  store." 
It  is  to  be  hoped  that  the  simple  but  truthful  story  of  the  working  girl  will  be 
read  and  her  appeal  for  industrial  and  social  betterment  answered.  To 
supply  the  need  spoken  of,  together  with  the  establishment  of  cooking 
schools,  and  kindergartens,  so  that  the  children  of  toil  may  at  least  have  an 
opportunity  to  learn  to  work  intelligently,  may  be  regarded  as  a  suitable 
field  for  practical  Christianity,  and  would  do  much  toward  narrowing  the 
breach  which  now  exists  between  the  church  and  wage  earners,  and  between 
capital  and  labor. 

While  the  character  and  variety  of  the  food  now  served  in  boarding 
houses  is  very  much  better  than  it  was  years  ago,  it  is  not  what  it  should 
be.  The  chief  fault  consists  in  improper  cooking,  and  the  widespread  error 
of  consuming  a  cold  meal  from  the  lunch  or  dinner  bucket. 

The  art  of  cooking,  and  how  to  supply  good  wholesome  food  in  proper 
quantities,  should  be  made  the  subject  of  popular  instruction.  The  ''Ladies 
Sanitary  Association  of  England,"  deserves  credit  for  having  taken  this 
matter  in  hand,  especially  since  experience  teaches  that  nothing  prevents  the 
abuse  of  alcohol  so  much  as  a  sufficient  and  palatable  supply  of  food. 

The  establishment  of  public  kitchens  and  eating  houses  for  unmarried 
laborers,  conducted  upon  practical  sanitary  and  economic  principles,  would 
prove  a  great  blessing. 

What  the  Employee  May  Do. — It  must  be  conceded  that  all  methods 
proposed  for  the  alleviation  of  the  effects  of  adverse  working  conditions  are 
prompted  by  the  spirit  of  humanity  and  as  a  social  duty.  Hence  it  is  reason- 
able to  expect  that  wage  earners  should  in  every  way  cooperate  and  avail 
themselves  of  the  various  safety  devices  and  preventive  methods  and  not 
underrate  their  importance  in  the  protection  of  health,  life  and  limb. 

While  it  is  criminal  for  employers  not  to  provide  suitable  protection  it  is 
equally  culpable  on  the  part  of  the  operatives  to  disregard  such  preventive 
measures.  So,  for  example,  it  is  not  a  pleasing  reflection  when  we  are  told 
by  the  Medical  Inspectors  of  the  State  Board  of  Health  of  Massachusetts, 
that  a  considerable  number  of  employees  remove  the  hoods  over  emery 
wheels  on  the  ground  that  they  interfere  with  their  work,  and  that  they  insist 
iron  enriches  the  blood.  Pr.ofessor  Harrington  in  speaking  of  respirators 
says,  "Aside  from  the  discomfort  caused,  the  operatives  have  another  and 
a  senseless  objection  to  their  use,  women  complaining  that  they  arc  made  to 
look  ridiculous,  and  men  l)eing  moved  to  discard  them  by  the  jibes  of  their 


r 


HYGIENE    OF    THE    HOUSE    AND    HOME  46 1 


more  reckless  fellows."  Dr.  Farrand,  former  Secretary  of  the  National 
Association  for  the  Study  and  Prevention  of  Tuberculosis,  spoke  to  me  of 
the  great  difficulties  he  and  others  had  encountered,  in  New  York  and  New 
Jersey,  in  inducing  the  operatives  to  give  safety  devices  a  fair  trial.  My 
personal  experience  and  that  of  other  social  workers  has  at  times  been  equally 
discouraging.  Time  and  again  have  the  good  intentions  of  employers  been 
frustrated  by  "self-willed"  workmen,  who  professed  to  know  better.  Even 
in  Government  arsenals  I  have  found  men  working  in  high  explosives  without 
rubber  gloves  and  respirators,  although  provided  by  the  Government. 

With  time  and  patient  education  these  difficulties  are  surmountable,  and 
it  is  just  here  that  the  intelligent  worker,  the  man  who  appreciates  the  value 
of  his  health  and  his  duties  to  his  family,  will  prove  an  efficient  coworker  in 
the  prevention  of  misery  and  distress.  It  is  hardly  fair  to  characterize 
certain  trades  as  dangerous,  when  experience  has  shown  that  no  harm  results 
when  proper  safeguards  have  been  taken.  In  the  consideration  of  this  ques- 
tion the  personal  element  of  the  workmen,  their  habits,  mode  of  life,  food, 
home  environments,  etc.,  cannot  be  ignored. 

There  are  a  number  of  occupations  in  which  the  alcohol  habit  prevails 
to  an  unusual  extent,  perhaps  because  of  the  character  of  the  work,  perhaps 
as  a  result  of  association,  and  it  would  not  be  fair  to  attribute  the  ill  health 
of  the  operatives  altogether  to  the  character  of  the  employment.  Again, 
many  persons  are  engaged  in  occupations  for  which  they  are  not  physically 
fitted,  while  others  ruin  their  health  by  vice,  dissipation,  improper  food,  and 
insanitary  environments  at  home.  The  writer  is  fully  convinced  that  the 
home,  and  home  influence,  play  a  very  important  role  in  the  causation  of 
so-called  "occupational  diseases."  As  early  as  1898,  under  the  leadership 
of  Surgeon  General  Sternberg,  he  helped  to  establish  a  company  for  the 
erection  of  sanitary  homes  for  wage  earners,  at  reasonable  rentals.  Later 
in  1908  as  Chairman  of  the  Committee  on  Social  Betterment  he  discussed  in 
detail  the  numerous  contributory  factors  just  alluded  to. 

Hygiene  of  the  Workmen. — House  and  Home. — Special  pains  should  be 
taken  in  the  selection  of  living  quarters  no  matter  how  humble  they  may  be. 
With  the  excellent  motor  facilities,  there  is  no  reason  why  crowded  tenements 
should  be  chosen  and  preference  should  always  be  given  to  individual  homes, 
or  apartments,  in  not  exceeding  two-story  tenements.  The  Germans  have 
an  old  but  true  proverb — "Where  the  sun  does  not  enter  the  doctor  surely 
will;"  hence  dark  gloomy  and  damp  houses  should  be  avoided;  mouldy  spots 
on  the  walls  or  ceiling  and  a  close  musty  odor  indicate  dampness,  and  cheap 
rents  should  prove  no  inducement  to  occupy  such  quarters.  Leaky  roofs 
and  down  spouts,  or  a  pile  of  ashes  against  a  brick  wall,  may  keep  the  house 
damp,  and  the  causes  should  be  promptly  removed.  In  all  such  instances, 
as  well  as  in  the  occupancy  of  a  recently  constructed  house,  it  is  very  desir- 
able to  dry  out  the  house  by  heat  and  open  windows. 

Since  we  know  that  the  mortality  from  contagious  diseases  increases  in 


462         ETIOLOGY    AND    PROPHYLAXIS    OF    OCCUPATIONAL    DISEASES 

proportion  to  the  number  of  inmates  of  the  rooms,  hygiene  requires  that  even 
the  most  modest  dweUings  should  afford  sufficient  room  to  prevent  over- 
crowding. Ventilation  is  always  necessary,  but  open  windows  are  especially 
indicated  at  night,  as  nothing  can  take  the  place  of  pure  fresh  air  in  small 
quarters.  This  may  be  effectively  accomphshed  without  the  danger  of 
draughts  by  opening  the  windows  in  the  bed  room  from  the  top,  and  those 
of  the  adjoining  room  at  the  bottom. 

There  are  many  famiUes  who  properly  insist  upon  having  a  sitting  room 
or  parlor,  which  is  most  commendable  if  the  bed  rooms  are  large  enough  to 
afford  at  least  500  ft.  of  cubic  air-space  for  each  occupant.  If  they  do  not  it  is 
desirable,  after  proper  airing  of  the  larger  rooms,  to  utilize, them  for  sleeping 
purposes,  for  it  must  be  remembered  that  the  air  of  habitations  is  vitiated 
by  the  consumption  of  oxygen  and  the  exhalation  of  carbonic  acid.  The 
airing  of  rooms  is  even  more  essential  in  cold  weather,  because  of  the  addi- 
tional pollution  by  carbonic  acid  from  Hghts  and  fires.  There  are  families, 
unfortunately,  who  for  various  reasons  are  obliged  to  live,  cook  and  sleep 
in  one  room,  and  for  whom  the  question  of  fresh  air  is  therefore  of  vital  im- 
portance. Such  families  should  not  hesitate  to  avail  themselves  of  the  bene- 
fit of  fresh  air,  especially  when  medical  science  has  demonstrated  the  ad- 
vantages of  fresh  and  even  cold  air  in  the  treatment  of  consumption  and  pneu- 
monia, provided  the  body  is  kept  warm  by  sufficient  bedclothes.  Night  air, 
contrary  to  popular  opinion,  is  not  unwholesome.  The  only  danger  is  from 
mosquitoes,  which  should  be  excluded  by  proper  screening  of  windows  and 
doors. 

Care  of  the  Skin. — The  skin  is  supplied  with  a  network  of  blood-vessels 
and  nerves,  and  is  a  sensory,  respiratory,  excretory  and  heat-regulating  organ. 
As  a  sensory  organ,  it  combines  with  the  tactile  functions  the  power  of  per- 
ceiving impressions  of  warmth  and  cold.  The  respiratory  functions  of  the 
skin  are  limited,  to  be  sure;  nevertheless,  small  quantities  of  oxygen  are  ab- 
sorbed and  carbonic  acid  is  eliminated.  Apart  from  this,  the  skin  of  an 
average  adult  eliminates,  through  the  sweat  glands,  about  23^^  lb.  of  water  a 
day.  Human  sweat  contains  about  2  per  cent,  of  solid  constituents,  mostly 
in  the  form  of  waste  matter  or  impurities,  and  the  odor  varies  in  different 
regions  of  the  body  and  in  different  races.  The  skin  also  secretes  a  fatty 
substance  through  the  sebaceous  glands.  As  the  water  from  the  skin 
evaporates,  the  solid  matter  remains  upon  the  surface,  combines  with  dirt, 
harbors  germs,  and  readily  undergoes  decomposition.  This,  apart  from  the 
disagreeable  odors  so  characteristic  of  unclean  persons,  also  tends  to  macer- 
ate the  skin  and  is  liable  to  produce  "galling  or  chaffing,"  pimples  and  boils. 
The  accumulation  of  this  matter  also  tends  to  close  the  pores  of  the  per- 
spiratory and  sebaceous  glands  and  to  throw  the  work  of  eliminating  the 
impurities  upon  other  organs. 

A  normal  cutaneous  function  is  doubtless  of  great  hygienic  importance, 
as  shown  l)y  the  occurrence  of  many  diseases  following  its  suppression,  be- 


HYGIENE    OF    THE    SKIN  463 

cause  in  such  an  event,  in  addition  to  the  retention  of  the  waste  matter  in 
the  blood,  work  is  thrown  upon  the  kidneys  and  other  eliminating  organs, 
and  these,  if  already  weakened,  naturally  break  down.  Since  the  functions 
of  the  skin  depend  not  only  upon  its  anatomical  intactness  but  also  upon 
cleanliness  and  a  proper  tone  of  the  cutaneous  vessels  and  nerves,  a  rational 
care  of  the  skin  demands:  (i)  That  it  should  be  freed  regularly  from  the 
secretory  products  and  particles  of  dirt;  (2)  that  the  cutaneous  nerves  retain 
their  normal  excitability  or,  when  impaired,  that  they  regain  their  tone;  (3) 
that  we  assist  the  skin  in  its  heat-regulating  functions,  so  that  it  may  not  be 
overtaxed — all  of  which  may  be  accomplished  by  ablutions,  baths,  and  suit- 
able clothing. 

Ablutions  and  Baths. — Regular  and  systematic  ablutions  with  soap  and 
water  are  requisite  for  reasons  already  given,  and  are  especially  necessary 
for  persons  engaged  in  dirty  work  or  exposed  to  poisonous  dust.  In  addition 
to  the  use  of  soap,  vigorous  friction  with  a  brush  should  be  employed,  not 
omitting  the  finger  nails,  on  account  of  disease  germs  and  industrial  poisons. 
The  hands  should  always  be  washed  before  meals  and  after  going  to  the  toilet. 

The  water  for  general  baths  should  not  be  too  hot,  as  this  would  relax 
the  skin  and  increase  the  susceptibility  to  catching  cold.  If  the  bathing  is 
not  done  in  a  bath  tub,  it  will  be  well  to  wash  and  dry  part  of  the  body  at  a 
time.  In  any  event  the  surface  should  be  wiped  dry  and  hard,  especially 
the  hair,  since  wet  hair  is  calculated  to  produce  colds.  It  is  always  a  good 
plan  to  wash  the  neck  and  chest  with  cold  water,  so  as  to  harden  the  skin. 

The  cold  bath  is  usually  taken  in  a  tub  or  by  means  of  a  shower  or  needle 
bath,  at  a  temperature  of  about  65°  for  adults.  It  should  not  last  over  3 
minutes.  Cool  baths  vary  from  65°  to  80°.  Tepid  baths  are  taken  at  a 
temperature  of  between  80°  and  90°,  continued  from  10  to  15  minutes. 
Warm  tub  or  shower  baths  vary  from  90°  to  100°,  and  are  generally  em- 
ployed for  their  cleansing  effect.  In  addition,  there  are  steam  or  Russian 
baths,  Turkish  or  dry  hot-air  baths,  river  and  ocean  baths,  swimming  pools 
connected  with  public  baths,  medicated  baths,  etc.  Swimming  baths  are 
particularly  useful,  as  they  also  afford  an  opportunity  for  muscular  exercise, 
and,  as  the  temperature  of  the  water  is  rarely  above  80°,  such  baths  are  both 
cleansing  and  stimulating,  and  therefore  an  excellent  tonic  for  the  skin.  All 
baths  should  be  followed  by  a  cool  douche,  and  friction  with  a  rough  towel 
should  be  employed  until  the  skin  is  in  a  general  glow.  The  value  of  bathing 
is  so  fully  appreciated  that  the  building  regulations  of  Washington  City 
compel  a  bath  room  for  every  apartment  offered  for  rent.  No  community 
should  fail  to  make  provisions  for  public  baths  for  summer  and  winter. 
The  necessity  for  washing  and  bathing  facilities  in  connection  with  industrial 
plants  has  been  pointed  out  on  page  443. 

Clothing. — The  object  of  clothing,  apart  from  the  moral  and  aesthetic 
aspect,  is  to  aid  the  skin  in  its  various  functions.  It  should,  therefore, 
afford  protection  against  heat  and  cold,  as  well  as  rain  and  mechanical  irrita- 


464        ETIOLOGY   AND   PR0PHYL.4XIS    OF    OCCUPATIONAL   DISEASES  | 

tion.  Clothing  must  be  adapted  to  climate  and  season,  and  extremes  should 
be  avoided.  As  a  general  rule  warm  woolen  goods  are  best  suited  for  winter 
wear,  and  cotton  or  linen  for  warm  weather.  It  should  be  understood,  how- 
ever, that  flannels  absorb  more  dirt,  odors,  germs  and  water  than  hnen  or 
silk,  while  cotton  occupies  an  intermediate  position.  The  question  of  wet 
clothing,  whether  from  perspiration  or  rain,  is  important,  as  the  drying  of 
clothing  on  the  body  involves  an  expenditure  of  animal  heat,  and  it  is  not 
a  matter  of  indifference  whether  this  takes  place  rapidly  or  slowly.  It  is  a 
fact  that  a  wet  cotton  shirt  or  sweater  feels  more  uncomfortable  and  colder 
than  a  wet  woolen  garment,  because  the  cotton  garment  dries  more  rapidly 
and  abstracts  during  the  same  time  more  animal  heat  than  flannels.  This 
is  not  without  a  practical  bearing,  as  it  teaches  that  persons  who  perspire 
easily  will  do  well  to  wear  flannels  next  to  the  skin.  This  is  all  the  more 
important  when  they  are  liable  to  drafts  or  abrupt  changes  in  temperature. 

As  a  protection  against  cold,  wool  is  superior  to  either  cotton  or  linen, 
and  should  be  worn  for  all  underclothing.  In  case  of  extreme  cold,  besides 
wool,  leather,  fur  or  waterproof  clothing,  on  account  of  their  impermeability 
to  air,  are  useful.  As  a  protection  against  cold  winds,  for  equal  thickness 
leather  and  India  rubber  take  the  first  rank,  wool  the  second.  As  a  protec- 
tion against  rain,  India  rubber  or  oiled  canvas  clothing  is  the  best,  but  it  is 
an  exceedingly  hot  dress,  owing  to  its  impermeability  to  air,  which  causes 
condensation  and  retention  of  the  perspiration.  To  overcome  this  objec- 
tion, Dumas  suggests  a  material  which  is  waterproof  and  yet  permeable, 
prepared  as  follows:  The  garment  is  placed  in  a  7  per  cent,  solution  of  gela- 
tine, heated  to  a  temperature  of  ioo°F.  After  immersion  for  a  few  minutes 
it  is  dried  in  the  air  and  after  drying  it  is  placed  in  a  three-fourths  of  i  per 
cent,  solution  of  alum  and  again  dried. 

As  a  protection  against  heat  in  the  shade,  the  thickness  and  conducting 
power  of  the  material  are  the  only  factors  to  be  considered.  Texture  has 
nothing  to  do  with  protection  from  the  direct  solar  rays;  it  depends  entirely 
on  color,  and  white  is  the  best.  As  a  protection  against  fire,  leather  clothing 
is  generally  worn.  The  fabric  can  be  rendered  non-inflammable  by  the 
addition  of  20  per  cent,  of  tungstate  of  soda  and  3  per  cent,  of  phosphate  of 
soda  to  ordinary  starch  sizing.  Cotton  or  linen  goods  may  be  treated  simply 
with  starch  and  borax,  in  the  proportion  of  a  teaspoonful  of  borax  to  3^^ 
pint  of  starch.     See  also  special  work  suits,  page  442. 

Clothing  as  a  Cause  of  Disease. — Clothing  may  impair  the  functions  of  the 
body  and  cause  disease:  1.  By  improper  fitting,  which  leads  to  compression 
of  blood-vessels  and  nerves  and  interferes  with  the  normal  position  of  organs 
and  the  movements  of  the  body.  2.  By  improper  selection  of  material, 
affording  either  insufficient  jirotection  or  overheating  a  part  or  the  whole  of 
the  body;  improper  material  may  also  produce  irritation  or  interfere  with  the 
ventilation  of  the  skin.  3.  By  wet  clothing  which,  in  drying,  may  abstract 
sufficient  animal  heat  to  cause  peripheral  irritation  and  reflex  internal  con- 


HYGIENE    OF    THE    SKIN  465 

gestions.  4.  By  poisonous  dyes,  such  as  compounds  of  arsenic  and  anti- 
mony, chrome  yellow,  zinc  chloride,  and  some  of  the  aniline  colors.  The 
toxic  symptoms  may  manifest  themselves  by  general  impairment  of  health 
or  by  local  infections  of  the  skin.  5.  Clothing  may  harbor  disease  germs, 
and  a  number  of  instances  are  on  record  in  which  itch,  smallpox,  tuberculosis 
and  scarlet  fever  have  been  spread  by  second-hand  clothing  and  bedding. 
This  points  to  the  necessity  of  thorough  disinfection. 

The  Head  Dress. — As  long  as  the  head  is  covered  with  hair,  the  head  dress 
should  be  permeable  and  not  too  warm,  thus  less  headache  may  be  induced; 
on  the  other  hand,  insufficient  covering  may  produce  neuralgia  and  rheumatic 
affections. 

The  head  and  eyes  should  always  be  protected  from  the  direct  rays  of 
the  sun,  and  for  this  purpose  broad-brim,  dark  felt  hats  or  caps  for  cold 
weather  and  straw  or  some  other  light-colored  material  for  summer  use  are 
the  best. 

For  the  Xeck. — Nothing  should  be  worn  around  the  neck  which  would 
overheat  the  parts,  dilate  the  blood-vessels,  and  render  the  skin  sensitive. 
The  collar  should  be  loose  fitting,  so  as  not  to  compress  the  blood-vessels. 
The  neck  ought  to  be  bared  as  much  as  possible,  and  hardened  by  frequent 
ablutions  with  cold  water. 

For  the  Body. — For  under  garments  the  union  suits  are  the  best.  They 
should  secure  a  normal  amount  of  warmth  and  be  so  arranged  as  not  to 
interfere  with  the  free  movement  of  the  chest,  or  compress  or  displace  the 
abdominal  and  pelvic  organs.  For  these  reasons  corsets  and  waist  bands 
are  wholly  inadmissable.  Suspenders  should  be  worn  by  both  sexes,  or 
women  m.ay  wear  a  bodice  arranged  for  the  attachment  of  skirts,  so  as  to 
suspend  their  weight  from  the  shoulders.  Steel  corset  stays  and  tight  lacing 
cannot  be  too  strongly  condemned,  because  there  is  ample  evidence  that 
they  have  caused  displacement  and  disease  of  the  abdominal  and  pelvic 
organs.  The  trousers  must  be  sufficiently  loose  around  the  waist  and  else- 
where to  permit  of  free  circulation  of  blood. 

Foot  Wear. — The  stockings  should  be  made  of  some  warm,  permeable, 
materia]  such  as  cotton,  merino  or  wool.  Tight  elastic  bands  or  constricting 
garters  are  liable  to  produce  varicose  veins.  Holes  and  rough  darning  of 
socks  should  be  avoided.  Boots  and  shoes  are  intended  to  protect  the  feet 
from  the  uneven  and  rough  surfaces  of  the  ground,  from  cold,  wet  and  even 
heat,  and  must  be  constructed  so  as  to  meet  these  requirements.  It  is  need- 
less to  insist  that  they  should  be  patterned  after  the  foot.  The  sole  of  a 
shoe  should  be  so  constructed  that  the  great  toe  touches  it  in  such  a  way  that 
a  line  projected  posteriorly  through  the  middle  of  this  toe  will  strike  the 
middle  of  the  heel.  The  heel  should  be  broad  and  of  medium  height,  so  as 
not  to  throw  the  weight  on  the  toes.  Across  the  tread  and  toes  the  sole 
should  be  sufficiently  broad  to  permit  of  lateral  expansion.  The  uppers 
should  be  soft  and  flexible,  but  not  too  roomy,  and  should  fit  snugly  around 
30 


466        ETIOLOGY   AND    PROPHYL.\XIS    OF    OCCUPATIONAL   DISEASES 

the  ankles  and  insteps.  In  occupations  involving  exposure  to  wet,  the  feet 
should  be  protected  by  rubbers  or  preferably  wooden  shoes. 

Since  cleanhness,  in  body  and  clothing,  is  next  to  Godliness,  frequent 
bathing  and  change  of  underwear  are  desirable.  It  is  also  a  good  plan  to 
use  nightshirts  or  pajamas,  so  as  to  afford  an  opportunity  for  a  thorough 
airing  of  the  underwear  worn  during  the  day. 

Care  of  the  Ears  and  Nose. — These  organs  should  be  kept  clean.  There 
is  danger  from  lodgment  of  foreign  bodies,  which  may  impair  the  hearing  for 
life,  especially  when  injudicious  attempts  at  removal  have  been  made.  In 
such  instances  it  is  always  best  to  consult  a  physician.  The  accumulation 
of  dust  in  the  ear  may  give  rise  to  inflammatory  conditions  and  favor  the 
development  of  impacted  ear  wax. 

The  chief  function  of  the  nose  evidently  is  to  arrest  more  or  less  of  the 
dust  and  germs  upon  its  mucous  surfaces,  and  in  cold  weather  to  warm  the 
inspired  air.  Much  of  the  dust  lodged  in  the  nasal  cavities  will  sooner  or 
later  find  its  way  into  the  stomach,  and  if  it  contains  toxic  substances,  may 
cause  industrial  poisoning.  In  cement  workers  actual  concretions  are  formed 
in  the  nasal  cavity,  hence  the  importance  of  cleanliness  and  of  breathing 
through  the  nose  instead  of  the  mouth.  In  order  to  do  this  without  discom- 
fort, it  is  necessary  that  there  be  no  obstruction  in  the  nasal  passages,  and 
persons  suffering  from  catarrh  or  other  symptoms  of  difficult  breathing  will 
do  well  to  undergo  treatment.  A  weak  solution  of  boric  acid  or  cooking 
salt  (a  teaspoonful  to  a  teacupful  of  warm  water),  gently  snuffed  from  the 
palm  of  the  hand  or  used  by  means  of  an  atomizer,  is  very  useful  in  the  pre- 
vention of  troublesome  and  even  serious  affections  of  the  nose. 

Care  of  the  Mouth  and  Teeth. — It  is  important  that  the  mouth  and  teeth 
be  kept  scrupulously  clean  at  all  times,  but  especially  in  occupations  involving 
exposure  to  toxic  dust  and  corrosive  fumes,  such  as  phosphorus,  mercury, 
etc.  In  addition  to  the  use  of  the  washes  just  mentioned,  with  which  the 
mouth  and  throat  may  be  rinsed,  the  teeth  should  be  well  brushed  before 
meals,  in  order  to  remove  any  industrial  poison  which  may  have  lodged. 
Quite  apart  from  this  danger,  oral  hygiene  demands  that  the  teeth  be  brushed 
upon  rising,  after  each  meal,  and  before  retiring,  and  the  gums  rubbed  with 
a  soft  cloth  saturated  with  a  strong  salt  solution.  Apart  from  the  corrosive 
action  of  fumes  and  industrial  poisons,  the  temperature  of  food  and  drink 
plays  an  important  role  in  premature  decay  of  the  teeth.  It  has  been  shown 
that  a  sudden  change  in  the  mouth  from  hot  to  cold  causes  the  enamel  to 
crack,  and  leads  to  decay,  because  the  microbes,  ever  present  in  the  mouth, 
find  these  fissures  a  suitable  lurking  place  for  their  destructive  work.  Food 
lodged  between  the  teeth  naturally  offers  a  suitable  medium  for  the  multi- 
plication of  these  germs.  Hence  the  necessity  of  cleanliness  of  the  teeth, 
which  is  best  secured  by  brushing  them  with  water  and  castile  soap.  In 
case  i)articles  of  food  cannot  be  thus  dislodged,  a  soft  silk  thread  drawn  be- 
tween the  teeth  will  accomplish  the  purpose  more  efifectively  and  wisely 


HYGIENE    OF    THE    EYES,    ETC.  467 

than  a  toothpick.  The  temperature  of  food  and  drink,  in  order  to  avoid 
cracking  of  the  enamel,  should  not  exceed  i2o°F.  or  fall  below  4o°F.  This 
question  also  plays  an  important  role  in  the  causation  of  dyspepsia. 

If  the  teeth  or  gums  are  already  painful  or  show  evidence  of  decay, 
accumulation  of  tartar,  or  the  presence  of  pus,  a  dentist  should  be  consulted. 
Many  cases  of  obscure  nerve  lesions  and  septic  infections  have  been  traced  to 
unsuspected  pus  cavities  in  the  mouth.  It  is  a  wise  plan  to  have  the  teeth 
examined  once  every  6  months,  and,  as  there  are  free  dental  infirmaries,  the 
question  of  cost  need  not  deter  even  the  least  resourceful  people. 

Care  of  the  Eyes. — ^The  protective  measures  in  the  way  of  suitable  eye 
shields  for  the  prevention  of  accidents  which  may  befall  the  eyes  have  been 
fully  set  forth  on  pages  307-316.  Whenever  there  is  any  evidence  of  redness, 
pain,  inflammation,  watering  or  "mattering"  of  the  eyes,  a  physician  should 
be  consulted.  While  free  bathing  with  cold  water  or  a  weak  solution  of  boric 
acid  may  exert  a  tonic  effect,  especially  in  dusty  occupations,  the  value  of 
good  eyesight  is  too  great  to  trust  to  domestic  remedies  or  even  to  the  services 
of  an  optician.  Whenever  there  is  any  difficulty  in  reading,  accompanied  by 
pain  or  headache,  an  oculist  should  be  consulted. 

Care  of  the  Hair. — From  what  has  been  stated  in  connection  with  indus- 
trial poisons,  it  is  apparent  that  the  head,  hair,  and  beard  offer  a  suitable 
place  for  lodgment  of  dust  and  condensation  of  toxic  vapors.  Apart  from 
the  local  irritant  effect,  there  is  a  certain  amount  of  danger  from  poisoning 
by  absorption  and  by  ingestion  of  particles  lodged  in  the  beard. 

It  is  well,  therefore,  for  workers  in  all  dusty  occupations,  especially  those 
exposed  to  industrial  poisons,  not  to  wear  beards  of  any  kind,  and  to  keep 
their  hair  well  trimmed.  In  addition  to  this  precaution  suitable  work  caps 
of  some  light  impermeable  material,  like  oiled  muslin,  should  be  worn,  and 
the  hair  thoroughly  washed  upon  cessation  of  the  work. 

Care  of  the  Hands  and  Nails. — The  finger  nails  should  be  kept  short  and 
hang  nails  properly  cared  for,  so  as  to  prevent  absorption  of  industrial  poi- 
sons and  septic  germs.  In  addition  to  frequent  ablutions,  there  is  need  in 
many  occupations  for  the  use  of  rubber  or  leather  gloves.  This  is  especially 
true  of  occupations  involving  exposure  to  strong  acid  or  alkaline  solutions, 
and  numerous  industrial  poisons,  especially  in  the  coal-tar  and  dinitro-com- 
pound  industry.  The  application  of  cocoa  butter,  vaseline  or  cold  cream  is 
useful  when  gloves  are  impracticable,  in  certain  occupations. 

Care  of  the  Feet. — Proper  foot  wear  will  prevent  corns  and  bunions,  which 
are  often  a  source  of  great  suffering.  It  is  important  that  the  foot  wear  be 
intact  when  exposed  to  industrial  poison,  such  as  lead,  chrome,  and  dinitro- 
compounds,  etc.,  in  order  to  prevent  absorption.  Warm  foot  baths  and 
change  of  stockings  are  desirable  upon  cessation  of  work,  not  only  in  danger- 
ous occupations  but  also  when  the  feet  ache  from  prolonged  standing  and  pro- 
fuse sweating.     The  application  of  a  weak  solution  of  alum  or  chlorinated 


468        ETIOLOGY   AND   PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

soda  is  useful  in  case  of  excessive  and  offensive  perspiration  of  the  feet. 
(See  also  page  445.) 

Care  of  the  Bowels.— All  sedentary  occupations  predispose  to  constipa- 
tion, which  in  turn  favors  pelvic  congestions,  hemorrhoids  and  uterine  dis- 
orders, not  to  mention  the  equally  important  consequences  of  auto-intoxica- 
tion, which  is  responsible  for  the  anaemia  and  disorders  of  the  nervous  system 
so  common  in  persons  with  constipated  habits.  In  some  instances  this  condi- 
tion is  due  to  neglect  to  answer  the  call  of  nature.  Regularity  of  the  bowels, 
at  least  one  evacuation  a  day,  is  essential  for  health,  especially  in  workers 
exposed  to  lead  and  arsenic.  The  most  natural  remedy  to  correct  constipa- 
tion will  be  persistent  effort  to  secure  evacuations  every  day  at  a  fixed  hour, 
aided  by  the  use  of  succulent  vegetables,  such  as  cabbage,  spinach,  greens, 
onions,  rhubarb,  "sour  kraut,"  fruits,  like  stewed  prunes,  figs,  apples,  etc., 
and  from  five  to  six  glasses  of  water  a  day.  Graham  or  rye  bread,  oat  meal, 
wheaten  grits,  butter  or  butterine,  olive  oil,  are  also  useful.  Milk,  cheese, 
eggs,  rice  and  tea  are  constipating. 

Exercise,  which  means  muscular  activity,  yields  heat  and  energy  and 
involves  a  more  rapid  combustion  as  shown  by  the  increased  elimination  of 
carbon  dioxide.  Exercise  leads  to  increased  muscular  development,  while 
inactivity  causes  a  wasting  or  fatty  degeneration  of  the  muscles. 

The  influence  of  exercise  upon  the  pulmonary  functions  is  well  marked 
since,  owing  to  increased  oxidation,  a  larger  amount  of  air  is  required  in  con- 
sequence of  which  the  number  of  respirations  is  increased.  Moderate  exer- 
cise therefore  tends  to  produce  better  oxygenation  of  the  blood,  increased 
lung  capacity  and  copious  ventilation  of  the  air  cells.  On  the  other  hand,  if 
the  exercise  is  violent  or  done  at  a  rapid  rate,  the  respirations  become  shallow 
and  sighing  and  thereby  materially  interfere  with  the  circulation  in  the  pul- 
monary capillaries  and  the  proper  oxygenation  of  the  blood. 

The  effects  of  exercise  upon  the  circulatory  apparatus  are  also  quite  marked, 
as  shown  by  increased  force  and  frequency  of  the  heart's  action.  During 
ordinary  exercise  the  action,  although  accelerated,  is  uniform  and  regular,  but 
during  violent  or  long-continued  exercise  the  muscles  of  the  heart  like  other 
muscles  become  tired,  as  shown  by  a  dicrotic  and  intermittent  pulse.  Palpi- 
tation of  the  heart,  a  rapid  irregular  pulse  and  inequality  of  its  volume  are 
indications  for  rest  and  of  danger  from  the  continuance  of  the  exercise. 

Exercise  increases  the  culancous  Junctions,  because  the  skin  in  consequence 
of  the  accelerated  circulation  and  heat  production  receives  more  blood,  and  in 
order  that  the  animal  temperature  may  be  kept  normal  copious  perspiration 
takes  place. 

Owing  to  the  increased  elimination  of  water  by  the  skin,  the  amount  of 
urine  is  usually  lessened,  but  the  solid  constituents,  especially  the  inorganic 
salts,  are  increased.  The  amount  of  urea  is  not  increased  and  may  even  be 
diminished,  in  which  case,  however,  there  will  be  a  compensatory  increase 
during  the  interval  of  rest. 


EFFECTS    OF    EXERCISE  469 

Exercise  exerts  a  decided  influence  on  the  digestive  Junctions .  In  order  to 
compensate  for  the  increased  consumption  of  carbon  and  water,  there  is  a 
desire  for  fatty  food  and  liquids,  the  digestive  functions  are  also  stimulated, 
but  exercise  immediately  before  or  after  meals  retards  digestion,  because  the 
muscles  calling  the  blood  from  the  stomach  and  internal  organs,  prevent  the 
proper  formation  of  the  digestive  fluids. 

There  is  no  doubt  that  the  brain  and  general  nervous  system  participates 
in  the  benefits  of  improved  nutrition,  secured  by  proper  physical  exercise. 
This  is  well  illustrated  in  the  person  of  Mr.  Roosevelt  whose  mental  and  bod- 
ily vigor  are  of  the  highest  order,  although  as  a  youth  he  had  a  delicate 
physique. 

Every  one  is  familiar  with  the  fact,  that  trained  muscles  respond  more 
promptly  to  volition,  a  matter  of  importance  in  many  pursuits  in  life. 

Effects  of  Overexercise. — If  a  certain  muscle  or  group  of  muscles  undergo 
severe  and  protracted  exercise,  they  become  tired  and  it  requires  considerable 
stimulus  and  will  power  to  set  them  again  in  action.  If  persisted  in,  the  mus- 
cular contractions  become  less  uniform,  trembling  and  even  muscular  spasms 
may  ensue,  followed  by  relaxation  and  soreness  of  the  parts.  These  phenom- 
ena disappear  upon  rest,  but  increase  in  intensity  and  lead  to  complete  in- 
effciency  upon  continuance  of  the  exercise  or  work.  The  tired  or  exhausted 
feeling  of  the  muscles  is  believed  to  be  due  to  an  accumulation  of  the  waste 
products  of  their  activity  (fatigue  toxins)  and  after  these  products  are  elimi- 
nated or  neutralized  the  muscles  resume  their  function.  This,  however,  is 
probably  not  the  only  cause,  for  we  know  that  a  certain  amount  of  depriva- 
tion of  oxygen,  or  rather  of  arterial  blood,  diminishes  muscular  energy  and 
leads  to  muscular  exhaustion;  hence  rest  is  essential  in  order  to  take  in  a  fresh 
store  of  oxygen.  The  ehmination  of  waste  products  is  important  as  their 
retention  renders  the  blood  impure  and  predisposes  to  disease.  In  addition  it 
should  be  remembered  that  the  heart  and  lungs  during  hard  work  or  exercise 
are  severely  taxed,  and  that  the  wear  and  tear  from  increased  blood  pressure 
and  accelerated  respiration  involves  the  expenditure  of  considerable  nervous 
energy,  which  adds  to  the  tired  and  exhausted  feeling.  Da  Costa  has  de- 
scribed a  weak  or  irritable  heart  especially  common  among  soldiers  and  pedes- 
trians which  he  attributes  to  overexertion  and  cardiac  strain.  Aneurysm 
and  rupture  of  blood-vessels  and  of  the  heart,  though  uncommon  before  mid- 
dle life,  have  followed  overexertion  and  hypertrophy  and  dilatation  of  the 
cardiac  muscles  are  not  infrequent  results.  A  person  with  valvular  disease 
should  avoid  violent  exercise  by  all  means. 

General  Rules  and  Kinds  of  Exercise. — From  what  has  been  said  it  is  ap- 
parently not  a  matter  of  indifference  as  to  how  we  employ  our  muscles.  In- 
sufficient exercise  not  only  affects  the  size  and  energy  of  the  muscles,  but  also 
impairs  the  respiratory,  circulatory,  cutaneous,  digestive  and  intellectual 
functions,  and  even  the  quality  of  the  blood  itself.  The  exercise  of  only  cer- 
tain groups  of  muscles  cannot  produce  a  harmonious  or  symmetrical  develop- 


470        ETIOLOGY    AND    PROPHYLAXIS    OF    OCCUPATIONAL    DISEASES 

ment  of  the  body  and  may  cause  disease  as  shown  by  the  numerous  deformi- 
ties and  neuroses  in  certain  occupations.  The  subject  of  exercise  is  of  less 
importance  to  wage  earners,  whose  work  requires  fairly  vigorous  exercise  in 
the  open  air;  indeed  there  are  many,  who  are  already  overworked,  but  to  the 
men  and  women,  including  brain  workers,  who  lead  a  sedentary  indoor  life, 
with  little  or  no  muscular  exertion,  the  question  of  exercise  is  of  the  utmost 
importance.  Among  the  many  excellent  means  of  muscular  exercise  are 
walking  to  and  from  the  work.  Professor  Haughton  has  shown  that  walking 
on  a  level  surface  at  the  rate  of  3  miles  an  hour  is  equivalent  to  raising  one- 
twentieth  part  of  the  weight  of  the  body  through  the  distance  walked.  The 
work  done  by  a  person  weighing  1501b.  in  walking  a  distance  of  3  miles  would 
be  equivalent  to  lifting  52  tons  i  ft.  high.  Most  authors  believe  with  Parkes, 
that  a  healthy  man  ought  if  possible  to  take  a  daily  amount  of  exercise  equiva- 
lent to  lifting  150  tons  i  ft.  high,  which  would  be  equal  to  a  walk  of  about  9 
miles,  but  as  there  is  much  exertion  even  in  ordinary  business  this  amount 
may  be  greatly  reduced. 

Swimming  calls  into  play  all  the  voluntary  muscles,  tends  to  expand  the 
chest  and  causes  extension  of  the  vertebral  column  and  is  therefore  especially 
suited  to  correct  the  effects  of  sedentary  habits  and  as  the  beneficial  effects 
also  extend  to  the  skin,  this  exercise  cannot  be  too  strongly  recommended  for 
both  sexes.  Dancing  and  skating  also  tend  to  expand  the  chest  and  develop 
the  muscles  of  the  extremities,  and  are  beneficial  provided  the  exercise  is 
carried  on  in  a  pure  atmosphere  and  is  neither  too  violent  or  protracted. 
Rowing  develops  to  a  marked  degree  the  muscles  of  the  arms,  chest  and  back, 
and  increases  the  vital  capacity  of  the  chest,  but  in  boat-racing  the  heart  and 
lungs  are  overtaxed.  Golf  is  especially  suitable  for  persons  who  lead  a  seden- 
tary or  indoor  life  and  can  be  safely  recommended  to  all,  where  age  precludes 
violent  exercise;  the  body  is  gently  exercised  in  all  its  parts,  and  there  is  no 
danger  of  overtaxing  any  particular  organ.  Tennis,  football,  baseball  and 
other  out-door  sports  are  more  violent  forms  of  exercise;  they  bring  into  play 
nearly  every  muscle  in  the  body  and  are  valuable,  but  if  pushed  too  far,  the 
heart  and  lungs,  especially  in  football,  are  severely  taxed.  Among  other  forms 
of  exercise  should  be  mentioned  bicycle  and  motor  riding,  clubs  and  dumb 
bells,  swinging  on  the  trapeze,  hanging  by  the  arms  and  legs,  bowling,  mili- 
tary drills  and  many  of  the  regular  gymnastic  exercises.  An  important  point 
is  to  vary  the  exercise  in  order  to  call  different  groups  of  muscles  into  play 
and  thus  produce  a  symmetrical  development  of  the  body.  Even  Celsus 
advised  to  swim,  ride,  fence,  sail,  row,  shoot  and  fish.  All  these  sports  will 
develop  the  muscles,  increase  the  chest  capacity,  stimulate  nutrition  and  the 
action  of  waste  eliminating  organs.  But  it  should  be  remembered  that  the 
greatest  good  is  accomplished  by  moderate  and  gradual  exercise  and  that 
violent  exercise  like  all  extreme  measures  is  hurtful.  As  to  the  amount  of 
exercise  perhaps  as  good  a  rule  as  any  is  laid  down  by  Lynch  in  his  "  Guide  to 
Health"  that  the  lean  should  exercise  to  the  glow  point,  or  until  their  bodies 


BRAIN    WORK 


471 


and  spirits  are  heated  for  that  will  fatten  them,  and  the  fat  should  exercise 
to  the  sweating  point.  He  considers  hypochrondriasis  and  hysteria  the  spe- 
cial punishments  of  ease,  affluence  and  indolence  and  that  the  more  luxuriously 
a  man  lives  the  more  exercise  he  needs. 

When  in  the  course  of  exercise  the  body  becomes  fatigued  or  the  heart 
and  respiration  embarrassed,  rest  is  indicated.  Exercise  should  not  be  under- 
taken, when  the  circulation  is  already  excited,  or  while  important  organs  of 
the  body  are  performing  their  functions,  as  for  instance,  immediately  before 
or  after  meals,  or  during  the  menstrual  period.  It  would  also  be  obviously 
wrong  to  begin  with  violent  exercise,  or  to  allow  sudden  cooling  of  the  body. 
Attention  should  also  be  paid  to  proper  clothing,  which  should  not  be  too 
warm  or  tight  fitting,  as  such  garments  result  in  accumulation  of  animal  heat 
and  interfere  with  free  movements  of  the  heart,  lungs  and  muscles.  After 
active  exercise  the  body  should  be  washed  with  soap  and  water  to  remove  the 
secretions  from  the  sweat  and  sebaceous  glands  and  the  surface  should  be 
well  dried.  If  a  bath  is  impracticable  and  the  body  is  in  a  state  of  perspira- 
tion, a  woolen  sweater  is  the  most  appropriate  garment  to  prevent  chilling 
of  the  body. 

Brain  Work. — Our  knowledge  of  the  effects  of  brain  work  on  metabolism 
is  not  at  all  satisfactory.  Hammond,  Gamgee  and  Paton  determined  an 
increase  of  urea  in  the  urine,  during  and  after  active  mental  labor,  but 
Caceneuve  and  Speck  were  unable  to  confirm  these  observations.  A  similar 
difference  of  opinion  exists  as  to  the  amount  of  phosphoric  acid  elimination. 
Immermann  observed  an  increased  elimination  of  CO2  during  brain  work, 
which  is  confirmed  by  Speck,  but  he  attributes  the  excess  not  to  the  mental 
efforts,  but  to  the  attending  muscular  movements. 

Some  authors  claim  to  have  observed  an  increased  animal  temperature, 
during  severe  mental  labor,  but  even  this  is  attributed  to  the  accompanying 
muscular  activity.  In  the  light  of  this  conflicting  testimony  it  is  evident 
that  the  influence  of  brain  work  on  metaboUsm  requires  further  elucidation. 
Practical  experience  teaches,  however,  that  studious  persons,  however  well 
:ed,  are  rarely  corpulent,  and  this  at  least  points  to  an  increased  consumption 
3f  carbon.  After  prolonged  mental  effort,  symptoms  of  mental  fatigue,  such 
IS  weariness,  headache,  inability  to  think  clearly  or  to  concentrate  our  ideas, 
imounting  at  times  to  complete  apathy  and  disgust  may  ensue;  these  symp- 
■-oms  disappear  upon  proper  rest,  but  unless  sufficient  recreation  is  taken,  this 
:ondition  is  liable  to  increase  the  intensity  of  the  headache,  and  produce  irri- 
;ability  of  temper,  restless  sleep,  chasing  of  ideas,  impaired  memory,  and  even 
iymptoms  of  mental  exaltation  or  depression,  and  other  typical  symptoms  of 
leurasthenia.  The  reason  for  this  is,  that  every  mental  effort  involves  an 
ncreased  flow  of  blood  to  the  brain,  and  unless  followed  by  intervals  of  rest, 
his  physiological  hyperaemia  may  become  permanent,  interfere  with  the 
lutrition  of  the  working  parts  of  the  brain,  and  thus  lead  to  pathological 
:hanges  in  the  brain  cells.     It  is  therefore  essential  not  to  overtax  the  brain, 


472        ETIOLOGY   AND   PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

and  to  allow  a  few  minutes  for  the  restoration  of  the  intracranial  circulation, 
after  every  continuous  mental  effort  of  50  to  60  minutes. 

While  it  is  true,  that  the  mind  may  be  stimulated  to  perform  an  immense 
amount  of  labor,  it  is  evident  that  this  involves  much  danger,  and  neither 
reason  nor  common  sense  can  justify  the  employment  of  such  stimulants. 

There  is  no  doubt  that  great  mental  work  can  be  borne  without 
serious  effects  if  hygienic  principles  of  diet,  exercise,  recreation,  and  other 
diversions  are  attended  to,  not  omitting  the  elements  of  hope  and  cheerful- 
ness, which  are  great  aids,  while  monotony,  worry  and  anxiety  have  a  most 
depressing  effect  and  probably  have  produced  more  neurasthenics  than 
hard  mental  work. 

Sleep. — Rest  and  sleep  are  Nature's  remedy  to  overcome  the  effects  of 
mental  and  physical  fatigue.  We  are  still  in  ignorance  of  the  exact  nature 
of  sleep,  or  the  suspension  of  the  automatic  activity  of  the  brain.  Some 
authors  maintain  that  it  is  caused  by  an  accumulation  of  waste  products 
(fatigue  toxins)  in  the  blood  and  central  nervous  system,  and  that  it 
ceases  with  the  elimination  of  these  products.  Others  believe  that  sleep 
results  from  the  exhaustion  of  the  supply  of  intramolecular  oxygen,  while 
still  others  attribute  it  to  a  temporary  anaemia  of  the  brain.  On  the  whole, 
there  is  much  reason  for  assuming  that  the  refreshing  effects  of  sleep 
are  due  to  the  elimination  of  waste  products  from  the  system  and  the  ab- 
sorption of  a  fresh  store  of  oxygen.  Sleep  in  an  abundance  of  fresh  air  is 
always  more  restful.  Adults  require  from  73^  to  8  hours.  If  the  amount  is 
materially  lessened,  languor,  pallor  and  nervous  irritability  may  be  observed. 
Excessive  sleep  is  harmful,  as  it  tends  to  produce  sluggishness  of  the  bodily 
functions,  lessens  tissue  metamorphosis  and  favors  the  deposition  of  fat. 
Irregular  bed  hours  are  not  calculated  to  promote  a  sound  and  refreshing 
sleep,  as  the  human  body  resents  irregular  habits  of  all  kinds.  The  objec- 
tions to  all  avoidable  night  work  are  largely  based  upon  the  fact  that  nor- 
mal sleep  is  seriously  interfered  with  in  day  time  by  light,  noises  and  in  hot 
weather  also  by  heat. 

Bed  and  Bedding. — Since  about  one-third  of  our  life  is  spent  in  bed, 
something  should  be  said  of  this  article  of  comfort  and  necessity.  As 
the  object  of  the  bed  is  to  promote  a  refreshing  sleep,  it  should  be  long  and 
broad  enough  to  permit  of  the  necessary  extension  of  the  body;  it  should  be 
elastic,  so  as  not  to  compress  the  soft  parts  unnecessarily,  and  it  should  be 
warm,  but  not  too  warm.  MetaUic  bed  steads  are  preferable  to  wood,  be- 
cause less  liable  to  be  infected  with  insects;  they  should  be  provided  with  a 
woven  wire  mattress  which  admits  of  free  circulation  of  air.  Upon  this  may 
be  placed  a  mattress  of  hair,  felt,  cotton  or  excelsior.  Pillows  should  be 
preferably  made  of  horsehair.  Feather  pillows  are  too  heating  for  the  head, 
unless  a  layer  of  paper  has  been  interposed.  High  pillows  are  objectionable, 
as  the  position  of  the  sleeper  would  impede  the  movement  of  the  diaphragm. 
Sheets  and  pillow  cases  of  cotton  for  winter  and  of  linen  for  summer  are 


ALIMENTATION    AND    FOOD 


473 


necessary   to   prevent   irritation  of  the  skin  and   soiling  of  the   mattress, 
pillows  and  blankets. 

The  most  suitable  coverings  for  a  bed  are  woolen  blankets;  they  are  warm 
and  their  permeability  admits  the  escape  of  gases.  For  warm  weather  a 
cotton  quilt  or  comforter  or  even  a  linen  sheet  is  preferable.  The  bedding 
should  be  aired  every  morning  and  exposed,  whenever  practicable,  to  sun- 
light, which  is  nature's  purifier  and  destroys  all  forms  of  germs. 

"Featherbeds"  and  "down  quilts"  are  warmer  than  blankets,  as  the 
air  contained  in  the  feathers  is  a  bad  conductor  of  heat,  but  they  are  suitable 
only  in  very  cold  climates,  or  for  anaemic  and  deHcate  individuals,  because 
they  overheat  the  body,  cause  dilatation  of  the  cutaneous  vessels  and  conse- 
quently relax  and  impair  the  tone  of  the  skin. 

The  sleeper  should  lie  with  his  head  slightly  raised,  preferably  with  the 
body  inclined  to  the  right  side.  He  should  rise  rather  slowly  from  the  re- 
cumbent position,  since  a  sudden  change  to  the  erect  position,  not  only 
accelerates  the  heart's  action,  but  also  changes  the  blood  distribution  too 
abruptly.  The  bed  should  be  so  placed  that  the  occupant  is  not  disturbed 
by  the  influence  of  light.  A  sound,  refreshing  sleep  can  be  had  only  when 
the  senses  are  no  longer  stimulated,  and  light  is  a  stimulus  which  acts  even 
through  the  closed  eyelids. 

Alimentation  and  Food. — The  human  body  needs  food,  air  and  water 
for  its  growth  and  maintenance  and  the  fact  that  proper  nutrition  of  the 
body  is  important  for  efl&ciency,  and  the  enjoyment  of  health,  has  long  since 
been  recognized. 

The  body  is  composed  of  about  60  per  cent,  of  water,  19  per  cent,  of  protein 
compounds,  15  per  cent,  of  fats  and  6  per  cent,  of  mineral  salts,  all  of  which 
are  sooner  or  later  consumed,  and  must  be  replaced  if  health  and  life  are  to  be 
preserved.  The  chief  objects  of  food  are  to  form  the  material  of  the  body 
and  to  repair  its  waste;  also  to  yield  heat,  to  keep  the  body  warm,  and  mus- 
cular and  other  power  for  the  work  it  has  to  do.  An  engine  cannot  run  a 
machine  or  draw  a  train  without  fuel,  which  is  converted  into  energy  or 
power.  In  the  same  way  the  body  must  have  fuel  in  order  to  generate  the 
power  expended  in  the  action  of  the  heart,  lungs  and  ordinary  muscular 
movements,  and  the  various  activities  of  man — ^whether  it  be  a  mason  in 
laying  stone  or  brick,  a  carpenter  in  sawing  or  driving  nails,  a  woman  who 
sweeps  or  does  her  household  work,  children  who  romp  and  play,  or  in  any 
of  the  avocations  of  life.     (Langworthy.) 

Food  stuffs  are  classified  according  to  their  proximate  composition  as 
follows:  I.  Organic,  which  includes  (a)  nitrogenous  food  material  commonly 
called  protein,  such  as  the  lean  part  of  meat,  milk  curds,  dairy  products, 
eggs,  the  gluten  of  wheat  and  other  cereals,  the  legumin  of  peas,  beans, 
lintels,  peanuts,  etc.  The  proteids  of  the  human  body  are  made  up  of  the 
same  chemical  constituents  and,  hence,  the  proteids  are  the  chief  tissue 
formers  of  the  body.     But  apart  from  this  purely  plastic  function,  they  can 


474        ETIOLOGY    AND    PROPHYLAXIS    OF    OCCUPATIONAL    DISEASES 

also  take  the  place  of  fats  and  carbohydrates,  if  the  body  has  not  enough  of 
one  or  the  other  for  fuel. 

(6)  -Non-nitrogenous  Foods. — These  are  derived  (c)  from  fats,  (b)  from 
carbohydrates  and  (c)  from  vegetable  or  organic  acids.  The  fats  derived 
from  the  animal  or  vegetable  kingdom,  such  as  butter,  butterine,  lard,  ham, 
bacon,  olives,  olive  oil,  cream,  cheese,  pecan  nuts,  walnuts,  hickory  nuts, 
etc.,. apart  from  aiding  in  the  reconstruction  of  fatty  tissue,  undergo  oxida- 
tion— i.e.,  they  are  burnt  up  in  the  body  and  thus  supply  heat  and  energy. 
The  carbohydrates,  such  as  starches  and  sugars,  whatever  their  source 
(potatoes,  cereals,  bread,  syrups,  fruits,  sweets,  etc.)  enter  the  blood  as  sugar. 
The  sugar  in  the  blood  is  carried  to  the  tissues,  where  it  is  burned  up,  yielding 
heat  and  energy.  The  vegetable  or  organic  acids,  like  tartaric,  malic, 
citric,  acetic,  oxalic  and  lactic  acid,  existing  in  fresh  vegetables,  fruits,  meats 
and  milk,  are  transformed  in  the  system  into  carbonates,  and  as  such  preserve 
the  alkahnity  of  the  blood.  In  the  absence  of  these  acids  in  the  diet,  the 
blood  becomes  impoverished,  and  scurvy  is  likely  to  develop.  The  cheapest 
substitute  for  fruit-acids  is  vinegar. 

2.  The  inorganic  food  stuffs  are  mineral  salts  and  water.  The  mineral 
salts  constitute  about  6  per  cent,  of  the  body  weight  and,  as  certain  quanti- 
ties are  daily  eliminated,  they  must  be  replaced.  The  phosphates  of  lime, 
potash  and  magnesia  contribute  largely  to  the  formation  of  bone,  and  are 
also  essential  for  the  growth  of  the  nervous  system.  Iron  is  required  for 
the  red  blood  corpuscles  and  coloring  matters.  The  chlorides  are  the  source 
of  hydrochloric  acid  in  the  gastric  juice,  and  keep  the  globulins  of  the  blood 
and  other  fluids  of  the  body  in  solution.  Potassium  for  the  blood  cells  and 
solid  tissues  and  sodium  for  the  intercellular  fluids  are  essential  for  the  growth 
and  repair  of  the  tissues.  The  fact  that  6o  per  cent,  of  the  body  is  composed 
of  water  clearly  indicates  that  a  sufficient  amount  must  be  introduced  to 
make  up  the  loss  sustained  by  its  excretion  through  the  lungs,  kidneys,  skin 
and  feces.  It  is  simply  necessary  to  recall  the  physiological  functions  of 
water  in  the  absorption  and  assimilation  of  food,  the  elimination  of  waste 
products,  and  its  role  as  a  heat  regulator,  to  appreciate  that  a  deficiency  is 
certain  to  be  followed  by  injurious  effects.  The  above  classes  of  food  stuffs 
are  essential  to  life.  There  is  a  third  class  known  as  food  accessories,  such 
as  tea,  coffee,  and  condiments;  these  are  important  as  favoring  palatability 
and  digestibility. 

Amount  of  Food  Required. — It  is  apparent  that  sufficient  food  must  be 
introduced  to  make  up  for  the  wear  and  tear  of  the  muscular  and  other 
tissues,  and  also  sufficient  fats  and  carbohydrates  to  supply  with  the  protein 
at  least  3500  calories  of  energy  per  day,  for  the  muscular  and  other  work 
the  body  has  to  perform.  By  the  term  calories  we  understand  the  amount 
of  heat  required  to  raise  the  temperature  of  a  pound  of  water  i°F.;  or  if 
transformed  into  mechanical  power,  such  as  the  muscles  use  to  do  their  work, 
a  calorie  represents  force  which  would  be  sufficient  to  lift  i  ton,  1.54  ft.  high. 


ALIMENTATION    AND    FOOD 


475 


.ccording  to  Atwater,  i  lb.  of  protein  or  of  carbohydrates  contains  i860 
alories,  while  i  lb.  of  fat  yields  4220  calories.  For  many  years  it  was  held 
lat  a  man  weighing  154  lb.,  and  performing  moderate  muscular  work, 
jquired,  during  the  24  hours,  118  grams  of  protein,  56  grams  of  fat  and 
DO  grams  of  carbohydrates;  while  a  man  performing  hard  muscular  work 
lould  receive  145  grams  of  protein,  100  grams  of  fat  and  500  grams  of 
irbohydrates. 

Professor  Chittenden's,  and  Rubner's,  more  recent  determinations  indi- 
ite  that  the  protein  ration  may  be  cut  in  two,  provided,  the  fats  and  carbo- 
ydrates  are  introduced  in  sufficient  quantities  to  bring  the  full  value  up  to 
500  or  2600  calories.  Other  authorities,  however,  believe  that  it  would  be 
awise  to  reduce  the  protein  ration  below  100  grams,  or  3.5  oz.  a  day,  or  the 
)tal  calories  of  energj'  below  3500  in  24  hours.  The  whole  subject  of  dietary 
andards  is  still  in  its  infancy  and  the  best  we  can  do  is  to  make  estimates 
hich  apply  to  averages  rather  than  to  individual  cases.  In  a  general  way 
e  may  conclude  that  the  needs  of  the  economy  are  influenced  (i)  by  the 
jight  and  weight  of  the  individual,  amounting  to  a  difference  of  40  to  50 
dories  for  each  kilogram  (2}^^  lb.)  in  body  weight;  (2)  by  the  tempera- 
ent — nervous  and  excitable  persons  require  more  food  than  those  of  a 
ilegmatic  temperament;  (3)  by  muscular  activity,  which  involves  not  only 
1  increased  expenditure  of  carbon  but  also  increased  consumption  of  pro- 
in;  (4)  age,  as  during  active  growth  there  is  also  a  more  active  metabo- 
m  and  children  consume  more  for  each  kilogram  of  their  weight  than  adults; 

I  the  other  hand,  wath  advancing  years  tissue  metamorphosis  becomes  less 
:tive;  (5)  sex  influences  the  amount  of  tissue  consumption  only  in  so 
r  as  there  is  a  difference  in  weight  and  muscular  activity — an  exception 
ould  be  noted  in  pregnant  and  nursing  women,  who  doubtless  should 
ceive  a  more  liberal  supply  of  proteids;  (6)  by  temperature  and  cHmate. 
tie  influence  of  low  temperature  results  in  increased  oxidation  of  carbon, 
nee  an  instinctive  craving  for  more  fatty  food  and  the  carbohydrates 
ugar  and  starches)  during  the  winter  months  and  in  cold  cHmates.  In  the 
mmer  months,  and  in  warm  climates,  there  is  a  repugnance  for  fat  and  a 
aving  for  refreshing  fruits  and  drinks;  hence  about  40  grams  of  fat  and 
:tween  300  and  400  grams  of  carbohydrates,  with  a  normal  protein  ration, 

II  meet  the  requirements. 

Cost  of  Food. — In  our  sociological  study  of  families  in  Washington  we 
and  that  476  families,  with  an  income  of  S500.00  or  less,  expended  43.68 
r  cent,  of  their  annual  income  for  food;  159  families,  with  an  income  of 
00  to  S600,  43.59  per  cent.;  153  families  with  an  income  of  S600  to  S700, 
.40  per  cent.,  and  153  families,  with  an  income  of  $700  to  $800,  40.21  per 
nt.  for  food.     The  question  of  food,  while  of  importance  to  all  classes  in 

relation  to  health  and  efficiency,  is  of  special  significance,  from  an  eco- 
mic  standpoint,  in  families  with  limited  means.  It  has  been  well  said 
at  "half  the  struggle  for  life  is  the  struggle  for  food." 


476        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

It  has  been  found  over  and  over  again,  that  persons  of  limited  means 
purchase  food  containing  little  or  no  nutriment,  or  select  needlessly  expensive 
kinds  of  food,  or  prepare  a  diet  altogether  too  one-sided,  and  lastly,  know 
little  or  nothing  about  the  art  of  cooking.  They  thus  impair  not  only  the 
nutritive  value  of  the  food,  but  also  the  digestive  functions  and  general 
health  as  well. 

In  order  to  give  housekeepers  of  moderate  means  an  opportunity  to 
select  suitable  dishes  I  requested  Prof.  C.  F.  Langworthy,  Expert  in  Nutri- 
tion of  the  U.  S.  Department  of  Agriculture,  to  prepare  for  the  President's 
Homes  Commission,  a  chapter  on  "good  food  at  reasonable  cost."  He  also 
prepared  a  table  for  the  use  of  housekeepers  who  desire  to  estimate  the  nutri- 
tive value  of  the  food  they  prepare.  The  table  shows  the  protein  and  energy 
value  of  the  portions  ordinarily  served,  of  the  more  common  articles  of  food. 

This  table  may  be  conveniently  used  by  supposing  that  the  food  eaten 
by  one  member  of  the  family  will  represent  in  character  and  amount  the 
food  for  the  entire  family.  To  estimate  by  means  of  the  table  the  food 
value  of  the  diet,  the  portions  of  each  article  used  at  each  meal  should  be 
set  down  in  order,  together  with  the  protein  and  energy  which  each  supplies 
and  the  total  sum  of  the  protein  and  of  the  energy  will  represent  the  amount 
eaten  in  the  whole  day. 

The  question  of  adequate  and  proper  food  for  persons  of  limited  means  is 
most  important  in  the  present  state  of  high  cost  of  living,  and  requires  judg- 
ment and  experience,  which  should  be  obtained  in  our  public  schools.  The 
foundation  of  a  suitable  diet  will  be  found  in  meat  milk,  butter  or  butter 
substitutes,  bread,  cereals,  rice  and  potatoes.  The  amount  of  cooked  meat 
need  not  exceed  $3^^  oz.  per  adult,  or  about  7  oz.  of  fish.  The  daily  require- 
ments of  fat  are  about  i  oz.  of  butter  or  oleomargarine,  or  i3^^  oz.  of  bacon — 
according  to  the  taste  and  circumstances  of  the  individual.  Codfish,  herring, 
milk,  butter  milk,  cottage  cheese,  peas,  beans  and  lintels  are  the  cheapest 
sources  of  protein,  and  can  replace  the  more  expensive  meat  and  egg  ration. 
Bread  is  a  cheap  source  of  both  starch  and  protein  and  has  long  been  called 
the  staff  of  hfe.  Oysters,  canned  vegetables,  except  beans,  and  fruit,  contain 
very  little  nourishment  in  proportion  to  their  cost.  A  mixed  diet  composed 
of  about  one-sixth  of  meat,  or  meat  substitutes,  three-sixths  of  bread  and 
cereals,  and  two-sixths  of  fresh  vegetables  and  potatoes,  with  sugar,  syrups, 
fruit  or  vinegar,  and  the  fats  already  referred  to,  will  be  found  both 
healthful  and  economic. 

Food  should  be  properly  cooked,  bills  of  fare  frequently  changed,  and 
relishes  and  flavors  should  not  be  wanting.  It  has  been  shown  that  the  pri- 
mary secretion  of  true  gastric  juice  is  the  result  of  a  reflex,  starting  in  the 
mouth,  and  that  the  relish  of  the  food  originates  the  reflex.  This  explains 
why  certain  dishes,  however  inexpensive,  "make  our  mouths  water,"  and 
why  distasteful  food  fails  to  cause  gastric  secretion.  Every  meal  should  be  a 
feast.     It  is  a  good  rule  to  eat  slowly,  to  masticate  thoroughly,  and  to  avoid 


ALIMENTATION   AND    FOOD 


477 


Approximate  Weight  and  Nutritive  Value  of  an  Average  Portion  of  Some  Common 

Foods 


Kind  of  food 


Average  wt. 
of  portion 


Average  bulk 
of  portion 


I  slice  of  roast  meat 

I  portion  of  meat  stew 

I  Frankfurt  sausage 

I  pork  chop 

1  slice  of  boiled  bacon 

I  portion  of  fried  bacon 

I  portion  of  steak 

I  portion  of  meat  soup 

I  portion  of  pea  or  bean  soup 

I  cup  or  glass  of  milk 

I  cup  or  glass  of  skim  milk  or  butter  milk 

I  portion  of  cream 

I  egg 

I  portion  of  butter 

I  portion  of  cheese 

I  baked  or  boiled  potato 

I  portion  of  turnip,  beet,  carrot,  or  similar 

vegetable 

I  ear  of  green  corn  or  i  portion  of  stewed 

corn 

I  tomato  or  i  portion  of  stewed  tomato . .  . 
I  serving  of  cooked  spinach,  cabbage  or 

other  green  vegetable. .' 

I  portion  of  baked  beans  or  black-eyed  peas 

I  slice  of  bread 

I  portion  of  corn  bread 

I  slice  of  cake 

I  slice  of  apple  or  other  fruit  pie 

I  cup  of  flour 

I  teaspoonful  of  sugar 

I  cup  of  sugar 

I  portion  of  sirup  or  molasses 

I  portion  of  cooked  cereal 

I  portion  of  dry  ready-to-eat  cereal 

Milk  for  cereal 

I  portion  of  boiled  rice 

I  portion  of  rice  pudding,  bread  pudding, 

or  similar  custard  pudding 

I  portion  of  cherry  roll  or  similar  pudding 

I  apple  or  pear 

I  banana 

I  orange 

I  peach  or  2  plums 

I  portion  of  stewed  prunes 

I  portion  of  preserves 

I  portion  of  fresh  berries 


Grras. 

85 
325 

60 
190 
100 

SO 
100 
190 
190 
225 
225 

65 

50 

10 

20 
140 

130 

75 
95 

125 

200 

50 

50 

SO 
150 
225 

10 
225 

75 
200 

50 

25 

140 

175 
175 
100 
100 

125 

75 
100 

65 
100 


Oz. 

3   

II   Saucerful 


7 

3^1 
2 

3K 


Cupful 
'Cupful 
I  Yt  pint 
I M  pint 

y^  gill 


3^|i-in.  cube 

2-3  I 

5     I  Med.  size  3  in.  long 


4K 


Saucerful 


3      Saucerful 
3  3^^  I  Saucerful 


Saucerful 
Saucerful 
4  X  4  X  I  in. 

3  X  3  X  I  in. 

4  X  2  X  I  in. 
J^  of  a  pie 
K  pint 


4M 

7 
2 
2 
2 

5 
8 

8 
23^ 

7 
2 
I 
5 

6 
6 

33^ 
3H 

23^ 

33^  Saucerful 
234  Saucerful 
33^  Saucerful 


>^  pint 

About  3^  gill 
Saucerful 
Saucerful 

Saucerful 

Saucerful 
Slice 


Pro- 
tein 

Grms. 

13 

32 

II 

46 

IS 
II 
26 

7 

7 

7 

7 

2 

7 


16 

4 
4 
3 
6 

19 


Energy 

'  CalT^ 
197 
461 
170 
765 
432 
252 
411 

SO 

70 

170 

85 
130 

96 

95 

94 
145 

80 

82 
25 

40 

300 

175 
142 
190 
440 
950 

40 
890 
200 
170 
200 

40 
15s 

300 
460 

SO 

70 

50 

35 
IIS 
150 

35 


478        ETIOLOGY   AND   PROPHYL.AXIS    OF    OCCUPATIONAL   DISEASES 

overeating,  especially  of  meat  and  eggs.     Hot  and  cold  food  and  drinijj 
hastily  swallowed  should  be  avoided.     (See  Teeth,  page  466.) 

From  our  knowledge  of  the  proximate  constituents  contained  in  varioi 
food  stuffs,  bills  of  fare  can  be  constructed  which  will  meet  the  requirement 
of  the  body  as  well  as  the  purse  of  the  consumer. 

Miss  E.  M.  Cross  of  the  McKinley  Manual  Training  School  prepared  fc 
the  President's  Homes  Commission  suitable  bills  of  fare,  for  summer  and  win 
ter  use,  for  a  family  of  moderate  income,  which  while  inexpensive  are  equal  i: 
food  value  to  the  best  hotel  fare. 

MENUS  FOR  WINTER  MONTHS 

MONDAY 

Breakfast.- — Hominy,  skim  milk,  cream  cake,  toast,  butter  or  butterine, 

coffee.     Protein,  28  grams,  Energy,  1053  calories. 

Dinner. — Irish    stew    with   dumplings,    boiled   rice,  cold    slaw,  apple 

pie.     Protein,  54  grams.  Energy,  171 1  calories. 

Supper. — Cottage    cheese,  bread,  butter,  molasses,  tea.     Protein,  13 

grams.     Energy,  818  calories. 

Total  Protein,  95  grams;  total  energy,  3583  calories. 

TUESDAY 

Breakfast. — Rice  cakes  (left  over  rice),  kidney  stew,  entire  wheat 

bread,  coffee.     Protein,  44  grams.     Energy,  11 76  calories. 

Dinner. — Corned  beef,  boiled  potatoes,  spinach,  tapioca  with  milk  and 

sugar.     Protein,  28  grams.     Energy,  842  calories. 

Supper. — Fried  mush,  cold  corned  beef,  bread,  butter,  tea.     Protein, 

29  grams.     Energy,   1196  calories. 

Total  Protein,  ioi  grams;  total  energy,  3214  calories. 

WEDNESDAY 

Breakfast. — Stewed  prunes,  meat  cakes,  corn  bread,  butter.     Protein, 

23  grams.     Energy,  771  calories. 

Dinner. — Split  pea  soup,  braised  beef's  heart,  boiled  cabbage  (corn  beef 

liquor),  boiled  onions,  potatoes,  apricot  roll,  vanilla  sauce.     Protein, 

56    grams.     Energy,    1572    calories. 

Supper. — Corned  beef  hash,  bread,  butter,  tea.     Protein,   29   grams. 

Energy,   1002  calories. 

Total  Protein,  108  grams;  total  energy,  3345  calories. 

THURSDAY 

Breakfast. — Rolled  wheat,  skim  milk,  Potomac  herring,  corn  bread, 

butter,  coffee.     Protein,  26  grams.     Energy,  866  calorics. 

Dinner. — Salt  pork,  potatoes,  turnips,  escarolle,  apple  butter,  short 

cake.     Protein,    61    grams.     Energy,    1530    calories. 

Supper. — Pigs'  feet,  potato  cakes,  bread,  butter,  coffee.     Protein,  23 

grams.     Energy,  840  calories. 

Total  Protein,  ho  grams;  total  energy,  3236  calories. 


THE    ALCOHOL   HABIT  479 

MENUS  FOR  SUMMER  MONTHS 
FRIDAY 

Breakfast. — Corn  flakes,  skim  milk,  salt-water  trout,  corn  dodgers, 

coffee.     Protein,  28  grams.     Energy,  896  calories. 

Dinner. — Stewed  tripe,  boiled  potatoes,  stewed  onions,  raw  tomatoes, 

bread,  rice  pudding.     Protein,  37  grams.     Energy,  11 75  calories. 

Supper. — Beef  stew,  corn  cakes,  butter,  stewed  apples,  tea.     Protein, 

41    grams.     Energy-,    1035    calories. 

Total  Protein,  106  grams;  total  energj-,  3106  calories. 

SATURDAY 

Breakfast. — Fried  tomatoes,  bacon,  bread,  butter,  coffee.     Protein,  31 
grams.     Energy,  1054  calories. 

Dinner. — Boiled  leg  of  mutton,  boiled  rice,  green  corn,  summer  squash, 
bread,  gingerbread.     Protein,  32  grams.     Energy,  1014  calories. 
Supper. — Cottage  cheese,  baked  potatoes,  raw  onions,  bread,  butter, 
gingerbread,  tea.     Protein,  25  grams.     Energy,  1048  calories. 
Total  Protein,  88  grams;  total  energy,  31 16  calories. 

SUNDAY 

Breakfast.- — Boiled  eggs,  Potomac  herring,  corn  bread,  butter,  coffee. 

Protein,  35  grams.     Energy,  8x8  calories. 

Dinner. — Chartreuse  of  mutton,  tomato  sauce,  boiled  potatoes,  string 

beans,  blackberries,  milk.     Protein,  44  grams.     Energy,  1187  calories. 

Supper. — Rice  muffins,  baked  tomatoes,  apple  butter,  coffee.     Protein, 

41  grams.     Energy,  1066  calories. 

Total  Protein,  120  grams;  total  energj',  3101  calories. 

THE  ALCOHOL  HABIT 

The  habitual  use  of  immoderate  doses  of  alcohol  cannot  fail  to  produce 
serious  injury  to  mind  and  body.  One  of  the  most  constant  effects  is  chronic 
inflammation  of  the  stomach,  with  consequent  impaired  digestion  and  nutri- 
tion. Alcohol  in  excess  also  produces  fatty  degeneration  of  the  heart,  liver, 
kidneys  and  arterial  coats,  and  is  one  of  the  most  common  causes  of  apoplexy 
chronic  meningitis,  insanity  and  affections  of  the  nervous  system,  such  as  in- 
flammation of  the  nerves,  palsies,  epilepsy,  etc. 

It  is  a  lamentable  fact  that  while  the  mortality  from  the  so-called  prevent- 
able diseases  has  markedly  declined  in  the  last  three  decades  the  death  rates 
from  the  diseases  referred  to  are  very  much  greater  than  in  1890.  This  is 
justly  attributed  to  the  ever  increasing  per  capita  consumption  of  alcoholic 
beverages. 

Every  physician  knows  that  the  alcohol  habit  not  only  predisposes  to 
tuberculosis,  pneumonia,  typhoid  fever  and  other  infectious  diseases,  but  also 
that  these  diseases  are  more  fatal  or  run  a  more  severe  course  in  alcoholic 
subjects,  probably  because  of  the  impaired  digestive  functions  and  a  general 


480        ETIOLOGY   AND   PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

depraved  nutrition  of  the  system,  with  consequent  diminished  power  of 
resistance. 

Alcohol  also  increases  the  susceptibility  to  industrial  poisons,  and  a  tend- 
ency to  rheumatism  and  gout.  According  to  Babcock  "there  is  a  distinct 
relationship  between  the  incidence  of  alcoholism,  insanity,  venery  and  crime." 
The  immoderate  use  of  alcohol  leads  to  mental  and  moral  deterioration,  char- 
acterized by  the  loss  of  will  power,  blunted  moral  sensibilities,  and  the  ruin  of 
character,  and  saddest  of  all,  these  effects  are  often  transmitted  to  the  off- 
spring. 

The  experience  of  43  American  Life  Insurance  Companies^"  on  alcohol 
in  relation  to  mortality,  shows  that  the  mortality  of  drinkers,  who  exceed 
two  glasses  of  beer,  or  one  glass  of  whiskey  daily,  was  18  per  cent,  in  excess  of 
the  standard  of  mortahty.  In  those  giving  a  history  of  alcoholic  excesses 
in  the  past,  the  mortality  was  50  per  cent,  in  excess  of  the  standard,  and  in 
the  moderate  steady  drinkers  the  mortality  was  86  per  cent,  in  excess 
of  the  standard. 


Comparative  Mortality  of  Males  25  to  65  Years  of  Age 


All  causes  complete 


All  males 

England 

and  Wales 


Brewers 


Innkeepers,  publicans, 

spirit,  wine  or  beer 

dealers 


Mortality  figures 

Diseases  of  the  nervous  system 

Respiratory  system 

Urinary  system 

Liver 

Alcoholism 

Gout 


119 

182 
41 
39 
10 

3 


1361 
144 
236 

55 
96 

25 
9 


1521 
200 
217 

83 

240 

55 
13 


Life  Insurance  Tables  Based  upon  English  Statistics  Cited  by  Jewett   (Town 

and  City,  Page  87) 


Age 


Average 

expectation 

of  life 


Moderate 
drinkers 


Total 
abstainers 


At  20  expect  to  live  to  be 
At  30  expect  to  live  to  be 
At  40  expect  to  live  to  be 


62 

65 
68 


35 


3,^ 


43  ?i 
513^ 


64 

66M 

68 


Alcohol  as  a  Cause  of  Accidents. — Considerable  evidence  might  be 
adduced  to  show  the  relationship  of  the  alcohol  habit  and  accidents.  Those 
who  are  familiar  with  the  effects  of  intoxicants  need  no  argument  in  favor 
of  sobriety.  All  railroad  corporations  and  industrial  plants  realize  the 
value  of  sober  habits  among  their  employees,  and  an  increasing  number  insist 
upon  total  abstinence  at  all  times,  whether  on  or  off  duty. 


THE    TOBACCO   HABIT 


481 


Preventive  Meastires. — The  problem  of  what  Hayhurst  calls  "industrial 

■  stimulantism"  must  be  solved  by  educational  methods,  and  hygiene  offers 

many  valuable  suggestions.     It  teaches  that  intemperance  is  a  vice    the 

result  of  a  violation  of  natural  laws,  and  in  order  to  eradicate  the  evil  we 

must  remove  the  primary  causes. 

Reference  has  been  made  on  page  448  to  mental  and  physical  fatigue 
as  an  important  predisposing  factor.  The  indications  are  to  regulate  our 
life  so  that  we  do  not  burn  the  candle  at  both  ends,  take  more  rest  and  more 
interest  in  general  amusements  calculated  to  counteract  the  influence  of 
saloons.  Hygiene  has  recognized  long  ago  that  dust-producing  occupations, 
exposure  to  extremes  of  heat  and  cold,  the  inhalation  of  toxic  fumes  and 
devitalized  air,  etc.,  are  fruitful  causes  of  disease  in  general,  and  the  drink 
habit  in  particular,  and  has  also  pointed  out  how  the  injurious  effects  may 
be  prevented  or  at  least  mitigated.  Until  this  is  accomplished  by  com- 
pulsory factory  sanitation,  pure  drinking  water,  and  non-alcoholic  beverages 
— preferably  milk — and  good  nourishing  soups  should  be  furnished  by  the 
employer. 

Every  one  at  all  familiar"  with  the  subject  knows  that  badly  cooked  food, 
especially  when  consumed  from  the  "cold  dinner  pail,"  produces  derange- 
ment of  the  stomach  and  a  craving  for  alcoholic  stimulants,  which  in  turn 
aggravate  the  original  digestive  disturbances  and  readily  lead  to  the  drink 
habit. 

In  our  sociological  survey  of  1217  famiUes  in  Washington,  D.  C,  earning 
less  than  $1000  a  year  we  found  the  average  expenditure  for  alcoholic  bever- 
ages to  be  $16.14  per  annum.  Of  the  750  wage  earners  who  carried  dinner 
pails  205  consumed  alcohoUc  beverages  with  their  meals. 

In  addition  to  the  causes  mentioned,  the  unnecessary  number  of  saloons, 
not  infrequently  connected  with  employment  agencies  or  located  in  the 
vicinity  of  workshops,  wharves  and  the  homes  of  wage  earners  increases  the 
temptation.  Last  but  not  least,  the  characteristic  American  bar,  drinks 
being  consumed  in  rapid  succession,  aided  by  the  pernicious  system  of  treat- 
ing, is  a  very  fruitful  cause  of  the  drink  habit. 

Money  spent  in  temperance  saloons  for  warm  wholesome  food  and  soups, 
cocoa  and  chocolate,  will  be  a  good  health  investment.  It  may  be  stated 
in  general  terms  that  while  coffee,  tea,  spices  and  condiments  in  moderation, 
stimulate  the  nervous  system  and  increase  temporarily  the  elasticity  of 
mind  and  body,  their  abuse  is  fraught  with  danger,  and  we  may  have  "coffee 
and  tea  and  even  coca-cola  topers,"  who  suffer  from  diseases  of  the  nervous 
system. 

It  is  sincerely  hoped  that  wage  earners,  in  addition  to  cultivating  home 
life  and  high  ideals,  will  hold  their  meetings  in  special  buildings  wholly 
divorced  from  saloons,  and  in  every  way  in  keeping  with  the  dignity  of 
labor. 

The  Tobacco  Habit. — The  per  capita  consumption  of  tobacco  in  the 
31 


482        ETIOLOGY   AND   PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

United  States  has  increased  from  6.31  lb.  in  1900  to  7.31  lb.  in  1910.  In 
view  of  the  fact  that  our  sociological  study  of  12 17  families  in  the  City  of 
Washington  in  1908  shows  an  average  annual  expenditure  of  $12.19  for  each 
family,  which  at  a  conservative  estimate  would  amount  to  $239,655,000  for 
the  annual  tobacco  bill  in  the  United  States,  it  is  important  to  consider  the 
effects  of  tobacco  on  the  system. 

Tobacco  owes  its  general  effects  to  the  presence  of  toxic  alkaloids  known 
as  nicotin,  nicoteUin,  nicotein,  nicotianin  and  certain  bases  such  as  pyrldin, 
picolin,  coUidin  and  others  which  are  formed  during  smoking.  Syrian  and 
Havanna  tobacco  contain  Httle  or  no  nicotin,  while  the  common  grades 
contain  from  3  to  4  per  cent,  and  even  10  per  cent.  The  acute  toxic  effects 
of  nicotin  are  familiar  to  all  who  have  learned  to  smoke.  Strange  enough, 
man  becomes  accustomed  to  the  toxic  effects  and  may  even  experience  an 
agreeable  excitation  of  the  nervous  system,  characterized  by  increased  mental 
and  physical  elasticity.  There  is  nothing  to  justify  the  assumption,  however, 
that  the  use  of  tobacco  is  free  from  danger.  Prof.  Seavers'  observation  on 
Yale  students  appears  to  show  that  non-smokers  made  not  only  the  best 
physical  gains  in  weight,  chest  measure  and  lung  capacity,  but  that  95  out 
of  every  100  of  the  best  students  were  not  smokers.  His  data  were  appar- 
ently so  convincing  that  Japan  in  1900  enacted  a  law  prohibiting  the  smoking 
of  tobacco  by  persons  under  the  age  of  twenty.  Dr.  A.  A.  Woodhull,  U.  S. 
Army,  holds  that  cigarette  smoking  by  the  young  is  harmful  as  it  arrests 
the  natural  eUmination  of  waste  and  hinders  the  utilization  of  fresh  material, 
thus  interfering  with  proper  growth  and  nutrition  of  the  body.  He  also 
believes  that  the  habit  develops  a  greater  tendency  to  acquire  an  appetite 
for  alcoholic  liquors,  premature  puberty  is  induced,  increasing  the  sexual 
propensity  and  leading  to  improper  sexual  practices.  There  is  a  consensus 
of  opinion  among  educators  that  the  use  of  tobacco  dulls  the  memory  and 
intellect.  When  a  promising  pupil  begins  to  decline  in  his  work  it  is  almost 
certainly  found  that  he  has  begun  the  use  of  cigarettes.  The  excessive  use 
of  tobacco  produces  a  chronic  form  of  nicotin  poisoning,  with  impairment 
of  vision,  nervous  irritability  or  exhaustion,  a  predisposition  to  neuralgia 
and  a  peculiar  affection  of  the  heart,  described  by  Professor  DaCosta  as  the 
tobacco  heart,  characterized  by  irregularity  of  the  heart  sounds,  accelerated 
action  and  weakness  of  the  cardiac  muscles.  Chewing  of  tobacco  is  even 
more  to  be  deprecated  than  smoking,  as  the  injurious  elements  are  dissolved 
by  the  saliva  and  not  infrequently  swallowed. 

In  many  instances  tobacco  in  any  form  produces  a  chronic  inflammation 
of  the  nose,  throat  and  stomach,  and  acid  dyspepsia.  Insomnia  and  bHnd- 
ness,  or  tobacco  amblyopia,  are  not  infrequently  observed  in  heavy  smokers. 
Tobacco  smoke  also  pollutes  the  air  of  the  room  with  coal  gas  and  the  toxic 
pyridin  bases. 

Some  authors  maintain  that  nicotin  is  decomposed  during  the  process 
of  smoking,  and  that  the  chief  harm  results  from  the  pyridin  and  furfural 


THE    TOBACCO    HABIT  483 

evolved  in  the  smoke.  Lehmann,^^  however,  recovered  in  the  smoke  82 
per  cent,  of  the  nicotin  contained  in  cigarettes,  and  85  to  97  per  cent,  in  cigars. 
The  London  Lancet^^  cites  analysis  showing  from  3.75  to  84  per  cent,  of  the 
original  nicotin  contents  in  the  smoke  from  cigarettes,  77  to  92  per  cent,  from 
tobacco  smoked  in  pipes  and  31  to  63  per  cent,  from  cigars.  The  injurious 
effects  of  tobacco  are  also  plainly  evinced  in  chewers  and  in  workers  exposed 
to  tobacco  dust,  showing  that  the  nicotin  and  not  the  pyridin  bases  is  the 
chief  toxic  factor.  KostiaF^  has  shown  that  72  of  100  of  the  female  employees 
in  a  Vienna  tobacco  factory  suffered  during  the  first  6  months  from  congestive 
headache,  palpitation  of  the  heart,  precardial  anxiety,  weakened  heart 
action,  intermittent  pulse,  pain  in  the  stomach,  heart  burn,  vomiting,  diarrhea, 
loss  of  sleep  and  appetite,  neuroses,  general  fatigue  and  loss  of  strength. 
These  symptoms  combined  not  infrequently,  in  acute  cases,  with  faintness, 
dizziness,  pallor  of  the  skin,  nausea,  vomiting,  profuse  perspiration  and 
diarrhea,  are  familiar  to  all  who  have  learned  the  use  of  tobacco  in  any  form, 
and  correspond  very  closely  to  those  observed  in  experiments  on  animals 
which  have  also  shown  that  nicotin  may  produce  hardening  of  the  arteries 
and  other  degenerative  diseases.^* 

Preventive  Measures. — The  use  of  tobacco  in  any  form  is  doubtless  a 
fruitful  cause  of  industrial  poisoning  among  wage  earners.  This  must  be 
apparent  when  we  recall  the  many  ways  in  which  lead,  arsenic  and  other 
toxic  substances  may  enter  the  mouth  by  soiled  fingers,  chewing  tobacco, 
pipes  or  cigars  which  have  been  contaminated  with  the  dangerous  agents. 
This  element  of  danger  has  been  recognized  and  in  quite  a  number  of 
European  countries  the  use  of  tobacco  during  working  hours  is  strictly 
forbidden.  The  employment  of  chewing  gum  will  not  obviate  the  dangers 
referred  to. 

On  the  whole  we  may  conclude  that  the  use  of  tobacco  is  not  a  physio- 
logical necessity,  and  its  abuse,  like  that  of  other  habit-forming  drugs  is 
doubtless  a  frequent  cause  of  a  breakdown.  It  is  especially  harmful  in 
nervous  subjects  and  those  of  insufficient  will  power  properly  to  restrict  its 
use.  A  German  authority  maintains,  and  no  doubt  correctly,  that  the  danger 
is  greater  from  smoking  cigarettes,  because  of  the  ease  with  which  the  smoke 
is  inhaled.  In  any  event,  the  practice  of  inhaling  the  smoke  into  the  lungs, 
or  smoking  before  breakfast,  is  a  bad  one.  Pipes,  cigar  or  cigarette  holders 
and  the  mouth  should  be  kept  clean.  Symptoms  of  shortness  of  breath, 
obscure  pains  around  the  heart,  and  nervous  irritability  and  cough  are 
indications  to  reduce  or  stop  the  habit  altogether. 

In  a  preliminary  report  on  Industry  and  Tuberculosis,  McSweeney  and 
Gunn^^  report  that  housewives  and  domestics  led  the  list  of  occupational 
classes  affected  by  tuberculosis  in  their  investigation  conducted  in  Massa- 
chusetts. Clerks,  including  salespeople,  bookkeepers  and  stenographers 
came  next.  Day  laborers,  workers  on  streets,  roads,  railroads,  subway  ex- 
cavations, constituted  the  third  largest  class.     Miscellaneous  factory  workers 


484        ETIOLOGY   AND   PROPHYL.AJCIS    OF    OCCUPATIONAL   DISEASES 

in  buttons,  corsets  and  typewriters  came  next.  Shoemakers  were  fifth. 
Mill  operatives,  the  cotton,  hosiery,  paper,  silk,  wool  and  worsted  industries 
came  next.  Teamsters,  waiters,  garment  workers,  stoneworkers,  woodwork- 
ers, bakers,  metal  workers,  printers  and  jewelers  also  reveal  an  unduly  high 
tuberculosis  incidence  (J.  A.  M.  A.,  June  3,  1916,  page  1813). 

REFERENCES 

1  Koelsch,  F. — Krankheit  u.  Soziale  Lage,  Miinchen,  191 2. 

2  Kaup,  J. — Archive  f .  Hygiene  VI,  1910. 

3  Bauer. — Gesundheitsgefahrliche  Industrien,  Jena,  190Q. 

*  Information  furnished  by  letter  in  1914  from  Dr.  Jno.  B.  Andrews,  Secretary  Am.  .\ssoc. 

for  Labor  Legislation. 
'  Oliver. — Diseases  of  Occupation,  London,  1908,  page  xvi. 

*  Transactions  XV.     Internat.  Congress  on  Hygiene,  Washington,  1913,  Vol.  Ill,  Part  II, 

pages  742-768. 
^  Koelsch.^— Krankheit  u.  Soziale  Lage,.  Miinchen,  1913. 
8  Shablowsky. — Zeitshft.  f.  Hygiene,  191 1,  Vol.  LXVIII,  page  209. 
'  Corbin,  H.  E. — Actes  des  TI  Congress  Maladies  Profession,  Brussells,  1912. 
^^  Scheuer,  O. — Die  Syphilis  der  Unschuldigen,  Wien,  1910. 
^^  Kober. — The  Transmission  of  Bovine  Tuberculosis.     Trans.  Assoc,  of  Am.  Physicians, 

1903. 
^^Lassar. — Deutsche  Med.  Woch.,  No.  40,  Oct.,  1902. 
^'  Perlen. — Lungenschwindsucht  u.  Beruf,  Munchen,  1887. 

^*  Gorgas,  W.  C. — J.  A.  M.  A.,  June  13,  1914,  page  i860.     General  Gorgas  was  invited 
by  the  Chamber  of  Mines  of  Johannesburg  to  investigate  the  causation  of  disease 
among  the  miners. 
^*  Cited  by  Munson,  Military  Hygiene,  1901,  page  521. 
i'5  Watkins-Pitchford. — The  Med.  Jour,  of  South  Africa,  April,  1914. 
1'  Ahrens — Archiv  f.  Hygiene,  1894,  Heft  2. 
1*  Graham-Rogers. — Report  N.  Y.  State  Comm.  of  Labor,  1911. 
*'  Kompendium  der  Gewerbekrankh,  Berlin,  1904,  page  106. 
2"  Watkins-Pitchford. — Med.  Journal  of  South  Africa,  April,  1914. 
^^  Shultes. — Deutsche  Med.  Wochenschft.,  1901,  page  546. 
2^  Military  Surgeon,  January,  1914. 

2^  Rubner. — Lehrbuch  d.  Hygiene,  Leipzig  u.  Wien.,  1906,  page  709. 
^^  Koelsch.— Krankheit  u.  Soziale  Lage,  Munchen,  1912. 

2*  Roth,  E. — Ermiidung  durch  Berufsarbeit  Internat.  Kongress  f.  Hygiene  and  Demog- 
raphic, Berlin,  1907,  Band  II,  page  618. 
"  Rubner. — Lehrbuch  d.  Hygiene,  Wien,  1899-1900,  page  701. 
*'  Zacher  Leitfaden  zur  Arbeitcrversicherung  d.  Deutschen  Reiches,  1906. 
"Town  and  City.      Jewett,  page  14. 

^'Neumann. — Deutsche  Med.  Wochenschft.,  1904,  page  1723. 
'*  Report  of  the  Medico-Actuarial  Investigation,  Vol.  III.     How  to  Live,  Fisher  and  Fisk, 

1915,  page  235. 
''Lehmann. — Mvinch.  Med.  Wochenschft.,  1908. 
'' Lancet,  London,  April  6,  191 2. 
"  Kostial  cited  by  Stephani,  Weyls  Handb.  der  Arbeiterkrankh.,  Jena,  1908,  pages  634- 

635- 
"  Jour.  A.  M.  A.,  LXII,  page  461. 

3*  McSweeney,  E.  F.,  and  (Junn,  Sclskar  M. — "Journal  of  Outdoor  Life,"  April,  1916,  page 
99. 


CHAPTER  I 

CHIEF   PROCESSES   INVOLVING   EXPOSURE   TO    OCCUPA- 
TIONAL INTOXICATIONS 

SECTION  I 
PROCESSES  INVOLVING  EXPOSURE  TO  ARSENIC   POISONING 

BY  GEORGE  M.  KOBER,  M.  D..  Washington,  D.  C. 

Mining.  Roasting  of  Arsenical  Ore.  ]Manufacture  and  Use  of  Arsenious  Acid  and  Color 
Pigments.  Arseniureted  Hydrogen  Poisoning  from  Employment  of  Impure  Com- 
mercial Acids.     Preparation  and  Use  of  Ferro-silicon — Preventive  Measures. 

WORKERS  IN  ARSENIC 

Mining. — Arsenic  is  usually  mined  in  the  form  of  arsenical  pyrites,  and 
when  thus  obtained,  the  mining  process  is  believed  to  be  free  from  danger 
as  regards  arsenical  poisoning.  It  has  been  suggested  that  the  inhalation  of 
dust  in  mining  of  an  arsenite  of  cobalt  may  be  responsible  for  the  undue 
prevalence  of  cancer  of  the  lungs  in  the  mining  district  of  Schneeberg  in 
Saxony.^ 

Roasting  of  Arsenical  Ores. — Pure  arsenic  is  obtained  by  roasting  native 
cobalt  or  arsenical  pyrites  in  special  furnaces  in  the  absence  of  air.  Arsenic 
volatilizes  and  is  condensed  on  the  sides  of  sheet-iron  tubes  which  are  attached 
to  the  retorts,  and  amorphous  arsenic  oxides  and  sulphides  are  condensed  in 
further  extension  of  these  tubes  which  are  sometimes  made  of  earthenware. 
The  men  engaged  in  this  process  and  also  in  the  smelting  of  other  ores  con- 
taining arsenic,  such  as  tin,  copper,  nickel,  lead,  iron  and  silver  ore,  are  liable 
to  suflfer  from  arsenical  poisoning,  generally  in  the  form  of  troublesome  skin 
affections.  Metallic  arsenic  is  used  to  impart  luster  and  to  harden  metal 
alloys,  and  in  the  manufacture  of  shot  to  harden  the  lead. 

Arsenious  acid  or  white  arsenic  is  secured  by  roasting  arsenical  ores  and 
smelting  residues  in  reverberatory  furnaces  with  free  access  of  air.  The  arsen- 
ical vapors  are  condensed  in  suitable  chambers  and  resublimed  in  iron 
cylinders.  White  arsenic  is  used  as  a  de-colorizing  agent  in  the  manufacture 
of  glass,  in  taxidermy  and  as  an  insecticide.  The  Factory  Inspector  of  East 
London,  cited  by  Neisser,'^  reported  in  1905  a  number  of  cases  of  skin  erup- 
tions in  persons  employed  in  packing  a  powder  containing  arsenic  and  to  be 
used  in  a  "dip"  for  scabby  sheep. 


486        ETIOLOGY   AND   PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

Arsenious  acid  is  also  used  in  the  manufacture  of  colors,  such  as  the  green 
pigment  known  as  Sheeles  green,  which  is  an  arsenite  of  copper  and  Schwein- 
furth  or  Paris  green  which  is  an  acetoarsenite  of  copper.  Other  arsenical 
pigments  are  used  in  connection  with  outside  paints,  as  mordants  in  dyeing, 
in  the  manufacture  of  colored  chalks  and  for  numerous  other  purposes. 
Analysis  of  a  sample  of  dust  secured  in  a  room  where  Paris  green  was  boxed 
revealed  the  presence  of  0.093  gram  of  arsenic  per  cubic  meter  of  air  and 
Dr.  Graham-Rogers  reports  that  as  a  result  of  spending  several  days  at  the 
plant  the  mucous  membrane  of  his  nose  as  well  as  that  of  Inspector  Vogt  was 
inflamed  for  some  time  after  their  visit. ^ 

Dr.  Alice  Hamilton  reports  cases  of  ulceration  of  the  skin  in  the  Paris- 
green  factories  of  Illinois,  and  states  that  the  workmen  are  continually  shifting 


Fig.  30. — Crude  method  of  drying  Paris-green.    Note  dust  on  walls. 
{Illinois  Factory  Inspection  Bulletin,  Vol.  i,  No.  i.) 

and  usually  all  suffer  from  arsenical  poisoning  by  the  end  of  the  season.  In 
the  manufacture  of  artificial  flowers  Sheeles  green  is  powdered  over  the 
leaves,  which  constitutes  a  very  objectionable  method.  According  to  Morris,'' 
from  I  grain  to  50  and  60  grains  of  this  pigment  have  been  found  per  square 
foot  in  green  wall-paper.  This  author  has  also  called  attention  to  the  fact 
that  stockings,  gloves,  etc.,  dyed  with  aniline  colors  often  cause  severe  irri- 
tation of  the  skin,  because  of  the  presence  of  arsenic,  which  in  his  opinion 
should  never  pass  into  the  finished  dye,  if  the  process  is  rightly  carried  out. 
Some  of  the  arsenical  salts  are  used  in  the  tanning  industry,  in  etching  on 
brass  and  bronze,  and  other  industries.     See  arsenic  in  the  list  of  industrial 


EXPOSURE  TO  OCCUPATIOXAL  INTOXICATIONS         487 

poisons.     It  is  a  remarkable  fact  that  the  number  of  cases  of  industrial  arsen- 
ical poisoning,  apart  from  skin  affections  is  comparatively  small. 

Arseniureted  Hydrogen  Poisoning. — The  majority  of  cases  of  industrial 
poisoning  from  this  gas  are  caused  by  the  employment  of  commercial  acids, 
such  as  sulphuric  and  hydrochloric  acids  derived  from  arsenical  p>Tites,  or 
the  action  of  such  acids  upon  arseniferous  metals. 

The  inhalation  of  this  gas  produces  a  toxic  form  of  jaundice  and  hemo- 
globinuria and  other  profound  symptoms  described  on  page  8. 

Prof.  John  Glaister^  of  the  University  of  Glasgow  presented  a  very  im- 
portant paper  on  industrial  poisoning  by  gases  of  arsenic,  based  upon  120 
cases  collected  by  him.  These  cases  have  been  enumerated  by  Dr.  Legge  on 
page  8. 

Of  39  cases  of  arseniureted  hydrogen  poisoning  reported  by  Prolss,^ 
of  which  19  proved  fatal  within  from  3  to  24  days,  12  were  chemists,  11  were 
engaged  in  filling  toy  balloons,  7  were  aniline  workers,  5  lead  smelters,  3 
were  balloonists,  and  in  one  the  occupation  is  not  stated.  Cases  have  also 
been  reported,  apart  from  the  processes  already  named,  in  smelter  works 
in  the  refining  of  silver  from  zinc  crust  with  impure  hydrochloric  acid,  and 
in  the  formation  room  of  accumulator  factories.  Three  cases  occurred  in 
England  in  an  electrolytic  process  for  the  recovery  of  copper. 

Rambousek^  reports  five  cases  which  occurred  at  Breslau  in  1902, 
of  whom  three  died  from  inhalation  of  this  gas  in  filling  toy  balloons.  In 
such  instances  the  hydrogen  gas  employed  is  usually  generated  by  the 
action  of  sulphuric  acid  upon  granulated  zinc  or  iron  which  frequently 
contains  arsenic.  The  cases  reported  as  having  occurred  in  paper-hangers 
wall  scrapers  and  even  in  occupants  of  rooms  decorated  with  arsenical  wall- 
paper are  in  part  caused  by  arsenical  dust,  but  the  cases  here  reported, 
clearly  refer  to  the  inhalation  of  hydrogen  arsenide  gas,  evolved  by  the 
growth  of  moulds  in  starch  paste  acting  chemically  on  the  arsenical  salt. 

Ferrosilicon. — Prof.  Glaister^  reports  a  series  of  interesting  cases  of 
poisoning  caused  by  the  combined  action  of  arseniureted  and  phosphureted 
hydrogen  during  the  transportation  by  sea  or  water  ways  of  ferrosilicon. 
This  material  is  an  alloy  of  iron  and  silicon  and  is  chiefly  used  for  the  manu- 
facture of  electrodes  and  in  the  production  of  steel,  and  thousands  of  tons 
are  annually  shipped  from  France  and  Germany  to  Great  Britain  and  the 
United  States.  It  is  also  manufactured  in  some  parts  of  this  country. 
Ferrosilicon  is  prepared  by  melting  together  iron  ore,  or  iron  or  steel  turn- 
ings, with  coke,  lime,  sand  or  quartz  at  a  temperature  of  2ooo°C.  in  electrical 
furnaces.  The  coke  reduces  the  quartz  and  ore  to  silicon  and  metal  with  the 
production  of  ferrosilicon.  Iron  and  quartz  often  contain  arsenic  and 
phosphorus  as  impurities,  which  are  not  removed,  but  are  converted  in  the 
presence  of  carbon  from  the  coke  into  calcium  phosphide  and  calcium 
arsenide.  The  grades  containing  30  per  cent,  or  less,  or  over  70  per  cent, 
of  siHcon  are  comparatively  innocous,  but  those  containing  between  40  and 


488        ETIOLOGY   AND    PROPHYL.'VXIS    OF    OCCUPATIONAL  DISEASES 

60  per  cent,  are  liable  to  decompose  on  exposure  to  air,  especially  in  the 
presence  of  moisture,  with  the  evolution  of  arseniureted  and  phosphureted 
hydrogen.  These  gases  are  not  only  fatal  to  animals  when  present  in  the 
proportion  of  H  to  i  per  cent.,  but  have  also  given  rise  to  explosions.  Most 
of  the  cases  of  poisoning  have  so  far  occurred  in  confined  air  spaces  on  board 
of  ships  and  canal  boats. 

The  symptoms  usually  develop  quite  suddenly,  and  are  characterized 
by  general  and  abdominal  pains,  nausea,  vomiting,  diarrhea,  hemorrhages, 
loss  of  consciousness,  dilated  pupils,  cold  clammy  perspiration  and  death 
from  coma.  Cases  of  poisoning  have  been  mistaken  for  cholera,  gastro- 
enteritis, ptomaine  poisoning  and  pneumonia. 

In  January,  1905,  50  steerage  passengers  on  the  S.  S.  "Vaderland"  en 
route  from  Antwerp  to  New  York,  and  lodged  over  the  hold  containing 
a  consignment  of  ferrosilicon,  were  seized  with  an  obscure  illness  and  11 
died.  The  deaths  were  certified  to  have  been  caused  by  pneumonia,  but 
on  account  of  suspicion  of  plague,  the  ship  was  quarantined  until  further 
investigation  led  to  the  conclusion  that  toxic  gases  evolved  from  the  ferro- 
silicon caused  the  illness  and  deaths.  In  October,  1905,  Dr.  Robertson 
reported  similar  cases  which  occurred  on  a  canal  boat  in  England,  whereon 
part  of  the  cargo  consisted  of  ferrosilicon.  The  brief  history  given  by 
Glaister  shows  that  the  whole  family  on  board  suffered  from  a  feeling  of 
sickness  and  giddiness  on  getting  up  in  the  morning  after  leaving  the  port, 
that  these  symptoms  passed  off  during  the  day,  but  reappeared  next  morn- 
ing, and  in  addition  there  was  also  pain  in  the  body,  headache  and  vomiting. 
On  the  third  day  the  symptoms  were  about  the  same  in  the  parents,  but  had 
assumed  a  very  grave  aspect  in  the  two  children,  aged  3  and  4  respectively. 
Dr.  Robertson  was  called  and  on  arrival  found  one  to  be  dead  and  the  other 
unconscious,  pupils  somewhat  dilated,  skin  covered  with  a  cold  clammy 
perspiration,  pulse  almost  imperceptible,  respiration  slow  and  shallow, 
with  crepitant  rales  all  over  the  chest.  This  child  also  died  soon  after  his 
arrival.  Post-mortem  examination  revealed  nothing  beyond  congestion  of 
the  lungs,  and  analyses  of  the  viscera  showed  no  trace  of  poison. 

In  December,  1908,  the  deaths  of  five  Jewish  emigrants  during  their 
voyage  from  Antwerp  to  Grimsby  on  the  Steamer  "Aston,"  first  attributed 
to  cholera  and  then  to  ptomaine  poisoning,  were  finally  traced  to  the  gases 
of  ferrosiHcon,  of  which  the  ship  carried  9  tons.  In  another  instance  cited 
by  Glaister  four  patients  died  on  a  Swedish  steamer  from  the  same  cause. 
For  treatment  see  Arsenic  and  Phosphureted  Hydrogen,  page  12. 

Preventive  Measures. — In  the  prevention  of  injurious  effects,  much  may 
be  done  by  the  substitution  of  harmless  colors  for  arsenical  pigments.  Until 
this  is  accomplished  special  attention  should  be  paid  to  the  employment  of 
wet  prcesses;  so,  for  example,  the  dusting  of  green  arseniferous  pigments, 
in  the  manufacture  of  leaves  for  artificial  flowers,  etc.,  from  a  dredging  box 
is  wholly  unjustifiable.     In  occupations  where  exposure  is  unavoidable  the 


EXPOSURE  TO  OCCUPATIOXAL  INTOXICATIONS  489 

hands  should  be  protected  with  rubber  gloves  and  the  air  passages  by  the  use 
of  respirators.  Strict  cleanliness  of  the  skin  and  clothing  are  essential  and 
the  rules  for  prevention  of  lead  poisoning  are  applicable  here.  The  possi- 
bility of  arseniureted  hydrogen  poisoning  in  the  various  occupations  referred 
to  emphasizes  the  fact  that  such  operations  should  never  be  carried  on  in 
confined  spaces  without  the  aid  of  efficient  mechanical  ventilation.  The 
manufacture  of  the  salts  of  iron  and  zinc  should  be  carried  on  in  closed 
chambers  connected  with  exhaust  flues.  In  the  employment  of  hydrogen 
gas  every  effort  should  be  made  to  secure  pure  reagents  and  to  avoid  close 
proximity  to  the  communicating  nozzle  and  escape  valves,  and  to  make  sure 
that  the  valves  and  hose  are  not  leaky. 

Rules  governing  the  transport  of  jerrosilicon  were  formulated  in  Sep- 
tember, 1910,  by  the  Prussian  Government.  It  is  required  (i)  that  ferro- 
silicon  be  packed  in  strong  water-tight  cases  of  wood  or  metal;  (2)  that  the 
words,  "ferro-silicon,"  "to  be  kept  dry,"  "with  care,"  be  legibly  and 
indelibly  inscribed  on  the  case;  (3)  that  the  substance  be  delivered  dry  and  in 
dry  cases;  (4)  that  the  cases  be  stored  in  airy  places  on  the  deck  of  the  ship 
in  such  a  manner  that  they  are  protected  from  wet. 

Dr.  Copeman,  Medical  Inspector  of  the  British  Local  Government 
Board,  suggests  the  following  international  regulations  for  the  ocean  trans- 
port of  ferrosilicon.  i.  Ferrosilicon  should  be  first  broken  up  into  pieces 
of  the  size  in  which  it  is  usually  sold,  and  should  be  stored  under  cover, 
but  exposed  to  the  air  for  at  least  a  month  before  shipment. 

2.  Manufacturers  should  be  required  to  mark  in  bold  letters  each  barrel 
or  parcel  of  ferrosilicon  with  the  name  and  percentage  grade  (certified  by 
chemical  analysis)  of  the  material;  the  name  of  the  works  where  it  is  pro- 
duced; the  date  of  manufacture;  and  date  of  despatch.  3.  The  shipment 
of  ferrosilicon  on  vessels  carrying  passengers  should  be  prohibited.  When 
carried  on  cargo  boats  it  should,  if  circumstances  permit,  be  stored  on  deck. 
If  it  be  considered  necessary  to  store  it  elsewhere,  the  place  of  storage  should 
be  capable  of  being  adequately  ventilated,  and  such  place  of  storage  should 
be  cut  off  by  airtight  bulkheads  from  the  quarters  occupied  by  the  crew  of 
the  vessels.  4.  This  regulation  should  apply  to  the  transport  of  ferro- 
silicon on  river  or  canal  barges  as  well  as  on  sea  going  vessels.  5.  Storage 
places  at  docks  or  at  works  where  ferrosilicon  is  used  should  have  provision 
for  free  access  of  air,  and  should  be  situated  at  a  distance  from  workrooms 
mess  rooms,  offices,  etc. 

A  Committee  of  which  Dr.  Copeman  was  Chairman  investigated  the 
accident  on  the  steamer  "Aston"  and  stated,  "the  proprietors  of  iron 
and  steel  works  making  use  of  ferrosilicon  will  assist  in  the  protection  of  their 
work-people  and  at  the  same  time  act  for  the  public  benefit  by  restricting 
their  orders  to  grades  of  this  material,  either  not  exceeding  30  per  cent., 
or  of  70  per  cent,  and  upward,  according  to  the  special  nature  of  their 
requirements." 


490        ETIOLOGY   AND   PROPHYL.\XIS    OF    OCCUPATIONAL   DISEASES 

REFERENCES 

1  Henry  Louis,  Oliver's  Dangerous  Trades,  1902,  page  538. 

2  Neisser-Internat.  tJbersicht  iiber  Gewerbehygiene,  1907,  page  77. 

^  An  investigation  as  to  the  danger  of  poisoning  from  lead  and  arsenic  in  industries  out- 
side of  Greater  New  York  by  C.  T.  Graham-Rogers,  M.  D.,  and  John  H.  Vogt,  B.  S., 
Report  of  the  New  York  State  Commissioner  of  Labor,  191 1. 

^  JMorris  Malcolm. — Oliver's  Dangerous  Trades,  1902,  page  381. 

^  Glaister. — Actesdull  Congress  Internat.  des  Maladies  Professionelles,  Brussels,  1910. 

'^  Proiss  F. — Bl.  f.  Gerichtl.  Med.,  1901,  page  171. 

'  Rambousek. — Industrial  Poisoning,  London,  1913,  page  145. 


SECTION  II 

PROCESSES    INVOLVING    EXPOSURE   TO   BRASS,   COPPER    (?), 
ZINC  AND  OTHER  POISONING 

BY  E.  R.  HAYHURST,  Columbus,  Ohio.  AND  GEORGE  M.  KOBER,  Washington,  D.  C. 

Founding  and  Casting.  Various  Poisons.  Preventive  IMeasures.  Cleaning,  Smoothing, 
Polishing  and  Buffing  Brass  Castings.  Manufacture  of  Professional  and  Scientific 
Instruments.  Manufacture  of  Electrical  Machinery,  Apparatus  and  Supplies. 
Storage  and  Dry  Batteries.  Incandescent  Lamps.  Manufacture  of  Bronze 
Powder.     Gilds.     Workers  in  Junk.     Mortality  Rates. 

Copper  ^Mining  and  Smelting.     Work  of  Coppersmiths.     Preventive  Measures. 

Zinc  Mining  and  Smelting.     Galvanizing. '  ^Manufacture  of  Zinc  Oxide. 

BRASS  INDUSTRIES 

BY  E.  R.  HAYHURST,  Columbus,  Ohio 

Founding  and  Casting. — In  the  brass  foundry  the  metal  is  poured  into 
sand  moulds  according  to  certain  patterns.  In  brass  casting  the  metal  is 
poured  into  iron  moulds  in  the  shape  of  bars,  tubes  or  rods  which  are  subse- 
quently rolled  or  drawn  out  into  sheets,  tubes  or  wire.  In  both  instances 
the  brass  is  melted,  as  a  rule,  in  crucibles  which  are  heated  each  by  itself  in 
a  submerged  cylindrical  furnace,  although  many  types  of  furnaces,  less 
objectionable  from  a  health  point  of  view,  are  beginning  to  be  used.  Scrap 
metal  is  dumped  into  the  crucible  first,  then  copper.  Just  before  removing 
the  crucible  from  the  furnace  (a  period  of  about  3  hours  from  the  beginning), 
the  zinc  ingots  are  shoved  well  under  the  surface  of  the  molten  copper  mass 
and,  after  removal  of  the  crucible,  but  just  before  pouring  into  the  moulds 
or  casts,  lead  is  usually  added.  The  workmen  are  divided  into  furnacemen, 
moulders  and  casters,  coremakers,  grinders  and  laborers.  Moulders  and 
casters  are  skilled  men  except  in  cases  where  machines  are  used.  In  America 
unskilled  men  are  largely  Eastern  and  Southern  Europeans.  Coremakers 
are  often  foreign  women,  who  work  in  separate  rooms  from  the  foundry  and 
make  fair  wages  at  piecework.  During  melting  and  pouring,  zinc  fumes 
arise,  and,  unless  provisions  are  made  for  confining  or  removing  them,  they 
fill  the  atmosphere  and  are  inhaled  by  all  those  in  the  vicinity. 

These  fumes  cause  the  afiiiction  called  "brass  founders'  ague,"  or  "zinc 
ague"  (see  Part  I),  Other  immediate  affiictions  of  brass  founders  are: 
(i)  lead  poisoning,  usually  from  auxiliary  processes;  (2)  nausea,  vomiting 
and  mucous  gastritis  from  sickening  oil  furnace  fumes;  (3)  heat  prostrations 
and  heat  colics  due  to  grave  metaboUc  disturbances;  (4)  gassing;  (5)  fatigue 
and  strain;  (6)  rheumatism  and  lumbago;  (7)  acute  bronchitis;  and  (8) 
industrial  alcoholism  (see  zinc  smelterers). 

491 


492         ETIOLOGY    AND    PROPHYLAXIS    OF    OCCUPATIONAL    DISEASES 

Various  Poisons.— The  investigators  of  the  Ohio  Survey  reported  ex- 
posure to  the  following  industrial  poisons  in  brass  foundries:  zinc  fumes,  lead, 
antimony,  carbon  monoxide,  carbon  dioxide,  sulphur  dioxide,  benzine,  phos- 
phorus and  "salamander  gases." 

Preventive  Measures.— The  brass  industry  needs  a  close  scrutiny  and 
very  material  improvement  in  all  branches  of  industrial  hygiene  before 


Fig.  31. — Casting  yellow  brass.  When  the  molten  metal  is  poured  into  the  moulds, 
fumes  of  zinc  arise  and  are  precipitated  by  the  cool  air  of  the  room  into  tine  gray  powdered 
flakes.  In  the  room  shown  these  are  unavoidably  inhaled  by  the  workmen  who  are  thus 
exposed  to  the  disease  known  as  brass  founder's  ague.  (Photo  taken  by  W.  C.  Hanson 
for  Mass.  .State  Board  of  Health.) 


workers  so  engaged  can  be  freed  of  the  risks  of  degenerative  diseases  and  an 
abbreviated  span  of  life. 

A  well-arranged  foundry^  is  a  roomy,  one-story  building  or  top  floor,  with 
impervious  flooring,  ceiling  vents,  large  windows  and  unhampered  by  high 
surrounding  eminences.  It  is  divided  into:  (i)  furnace  room,  or  at  least 
partial  partitions  provide  adeciuate  up-and-down  ventilation  in  the  furnace 


EXPOSURE    TO    OCCUPATIONAL    INTOXICATIONS 


493 


area;  (2)  casting  room,  or  an  area  covered  by  broad  spreading  exhaust  hoods 
beneath  which  pouring  is  d<5ne;  (3)  moulding  shop,  where  moulds  are  made 
(an  entirely  cold  process) ;  (4)  core  room,  which  has  the  core-baking  ovens 
well  apart;  (5)  grinding  and  sand-blasting  rooms,  equipped  with  exhaust 
ventilation,  where  rough  castings  are  smoothed  down;  (6)  change  house,  or 
quarters  provided  ^\ith  lockers  on  one  side  for  street  clothes,  shower  baths 


Fig.  ^2. — Casting  yellow  brass.  Brass  workers  are  here  protected  from  zinc  fumes 
by  an  adequate  exhaust  system.  (Photo  taken  by  W.  C.  Hanson  for  the  Mass.  State 
Board  of  Health.) 

in  the  center,  and  lockers  for  work  clothes  on  the  other  side;  (7)  luncheon 
quarters.  At  present,  a  very  few  foundries  in  America  approach  this 
standard.  In  most  instances  all  or  nearly  all  the  above  processes  are 
carried  on  in  the  same  room,  often  low-ceilinged,  while  doors  and  windows 
with  perhaps  a  few  small  openings  in  the  roof — -all  of  which  are  closed  in  the 
winter  time — are  depended  upon  for  ventilation. 

Furthermore,  prophylaxis  consists  in  selecting  workmen,  regulating  their 


494        ETIOLOGY   AND    PROPHYL.-VXIS    OF   OCCUPATIONAL   DISEASES 

habits  and  work,  then  Hmiting,  confining  or  removing  the  fumes.  The 
adoption  of  the  electric  furnace  promises  much"  in  this  respect.  Aerial  dilu- 
tion of  the  fumes  is  not  enough.  All  furnace  areas  and  pouring  areas  should 
be  provided  with  hoods  and  stacks  to  draw  off  vapors.  The  Germans  are 
using  flexible  exhaust  ducts  which  are  locally  appHed  during  pourings.^ 
In  addition,  the  foundry  rooms  need  air-agitators  (fans),  and  arrangements 
for  vertical  (floor-ceiling)  ventilation  which  is  most  apt  to  be  efl&cient  irre- 
spective of  weather  and  wind  conditions.  The  wearing  of  respirators  although 
a  help  will  not  prevent  the  inhahng  of  gas  or  fumes.  The  more  zinc  oxide  in 
the  air  the  more  imperatively  are  regulations  and  improvements  needed. 
Foreign  countries  have  adopted  extended  regulations  for  smelting  and  found- 
ing industries  and  marked  results  have  already  been  produced  according 
to  their  statistics.^ 


Courtesy  of  Crane  Co. 

Fig.  33. — Crucible  of  yellow  brass.     Approved  method  of  handling. 
{Illinois  Factory  Inspection  Bulletin,  Vol.  I,  No.  i.) 

Fortunately  the  vast  majority  of  brass  workers  are  employed  outside 
of  the  foundry  in  finishing  processes,  such  as  polishing  and  buffing  (very  dusty 
work,  but  in  the  past  10  years  rendered  practically  harmless  by  exhaust 
systems  locally  applied),  machinery  and  assembling  work,  plating,  lac- 
quering, etc.  Among  assemblers  of  brass  parts,  as  chandelier  makers,  lead 
poisoning  occasionally  occurs  due  to  the  careless  use  of  white  or  red  lead 
paste  in  hermetically  scaling  joints. 

Cleaning  and  Smoothing  of  Brass  Castings.* — This  process  is  accom- 
plished in  several  ways.  One  method  is  by  chipping  the  rough  castings 
*By  George  M.  Kobcr. 


I 


EXPOSURE  TO  OCCUPATIONAL  INTOXICATIONS 


495 


with  pneumatic  chisels  or  by  means  of  "sand  blasting,"  In  some  of  the 
factories  the  smaller  castings  are  cleaned  by  hand  with  steel  wire  brushes, 
or  with  mechanical  revolving  wire  brushes,  or  by  being  mixed  with  small 
pieces  of  scrap  iron  and  then  rotated  in  "tumblers"  or  "rattlers."  The 
constant  friction  of  the  castings  upon  each  other  and  the  scrap  iron  removes 
the  sand  and  all  rough  surfaces. 

Polishing  and  Buffing. — This  is  usually  accomphshed  by  the  employment 
of  emery  wheels  and  the  final  burnishing  of  brass  is  done  on  "bufl&ng  wheels" 


Fig.  34. — Buffing  brass.  The  buffing  wheels  shown  are  well  equipped  with  hoods 
and  blowers  and  give  off  practically  no  dust  or  lint.  (Supplied  by  W.  C.  Hanson  for  the 
Mass.  State  Board  of  Health.) 

covered  with  leather  or  circular  pieces  of  cotton  cloth.  All  of  the  processes 
referred  to  are  extremely  dusty  and  expose  the  operatives  to  the  inhalation 
of  a  conglomeration  of  dust  and  also  to  injuries  of  the  eyes. 

A  number  of  cases  of  plumbism  are  annually  reported  among  the  polishers 
or  buffers  of  brass  goods,  especially  of  spiggots.  Gun  and  pot  metal  contain 
usually  from  5  to  6  per  cent,  of  lead,  but  the  Medical  Inspector  of  Great 
Britain^  has  reported  instances  of  lead  poisoning  in  brass  polishers  in  which 
analyses  revealed  the  presence  of  only  2.4  to  2.9  per  cent,  of  lead.  The 
factory  inspector  of  the  State  Board  of  Health  of  Massachusetts^  also  points 
out  that  many  of  the  brass  poHshers  are  pale  and  emaciated,  their  teeth  in 


496        ETIOLOGY   AND   PROPHYLAXIS    OF   OCCUPATIONAL   DISEASES 

a  bad  condition  and  the  gums  showing  the  characteristic  bluish  discoloration. 
Dr.  Wm.  Murray®  was  the  first  to  point  out  that  the  cases  of  lead  poisoning 
in  "chandeUer  makers"  are  contracted  by  the  habit  of  fitting  the  joints  with 
lead  and  then  testing  them  by  closing  one  end  and  sucking  the  other  end  of 
the  bracket. 

As  in  the  case  of  copper  goods  a  dip  of  dilute  sulphuric  acid  is  quite 
generally  used  and  naturally  adds  to  the  danger.     The  use  of  japan  mixed 


Fig.  35. — Buffing   brass.     No   dust-removal   device  is  here  provided  for  the    protection 
of  employees.     (Supplied  by  W.  C.  Hanson  for  the  Mass.  State  Board  of  Health.) 


withwood alcohol a.nd  of  Zapone  lacquer  (amyl  acetate)  as  a  final  finish  to  chan- 
deliers, art  goods,  etc.,  is  injurious  to  the  health  and  calls  for  special  protec- 
tion in  the  way  of  exhaust  ventilation  and  steam-heated  drying  chambers. 
(See  page  721.) 

Instruments,  Professional  and  Scientific. — The  most  important  unhy- 
gienic processes  involved  in  the  manufacture  of  such  instruments  are  those 
already  referred  to,  such  as  machine  shopping,  soldering,  welding,  polishing, 
buffing,  electroplating,  etc.  In  the  manufacture  of  optical  lenses,  microscopes, 
etc.,  there  is  also  exposure  to  dust  from  glass  and  rouge  (iron  peroxide) 
during  the  grinding  and  polishing  processes,  and  in  the  manufacture 
of  barometers  and  thermometers  there  is  exposure  to  lead  and  mercury. 


EXPOSURE  TO  OCCUPATIONAL  INTOXICATIONS         497 

Makers  of  muscial  instruments  often  acquire  lead  poisoning  by  filling  the  in- 
struments with  molten  lead  before  the  shaping  process. 

Electrical  Machinery,  Apparatus  and  Supplies. — The  manufacture  of 
electrical  switch  boards,  meters,  telephones,  registering  devices,  etc.,  involves 
hazards  common  to  the  brass  industry,  except  that  the  workers  on  electric 
meters  and  electrodes  are  also  exposed  to  mercury. 

Storage  Batteries. — The  occupational  risks  in  the  manufacture  of  storage 
batteries,  from  lead  poisoning,  have  been  referred  to  on  page  115.  The 
dangerous  process  consists  in  the  casting,  dressing  and  polishing  of  perforated 
or  grooved  lead  plates,  the  connection  of  these  plates  by  the  use  of  solder  and 
blowpipe  and  the  employment  of  lead  oxide  paste  and  sulphuric  acid.  The 
rapid  solder  employed  in  storage  battery  work  also  contains  mercury.  In 
many  establishments  fuUy  50  per  cent,  of  the  workers  have  been  known  to 
contract  lead  poisoning,  some  of  them  within  10  days  after  beginning  the 
work. 

Dry  Batteries. — The  manufacture  of  dry  batteries  involves  exposure  to  a 
number  of  industrial  poisons,  such  as  benzol,  creosote,  hydrochloric  acid,  lead 
during  the  soldering  process,  mercury  during  the  amalgamizing  process, 
pitch  and  zinc  chloride.  Inflammatory  conditions  and  fissures  of  the  skin  and 
chloride  of  zinc  and  acid  burns  are  not  uncommon.  Cancer  of  the  skin, 
attributed  by  some  authors  to  carbon  dust,  the  use  of  pitch  and  chemicals, 
has  been  reported. 

Incandescent  Lamps. — One  of  the  chief  characteristics  of  this  industry 
is  the  overwhelming  number  of  female  employees  and  the  "speeding-up" 
incident  to  piecework.  Much  of  the  work  is  done  in  close  quarters  and  in- 
volves exposure  to  industrial  poisons.  Commendable  progress  has  been 
made,  however,  and  the  Ohio  Survey  reports  that  none  of  the  employees  were 
exposed  to  mercury,  which  was  used  in  closed  containers  to  produce  a  vacuum, 
and  that  red  phosphorus  was  used  instead  of  the  white  or  yellow  variety  in 
painting.  The  chief  hazards  in  each  of  the  different  departments  found  by 
Hayhurst  were  as  follows:  Filament  making:  wood  alcohol,  gas  fumes,  heat, 
inadequate  ventilation.  Tubulating,  sealing  and  painting:  the  hazards 
already  mentioned,  also  exposure  to  glass  dust,  foreign  bodies  in  the  eyes,  small 
cuts  and  burns.  Vacuum  production,  photometry  and  aging:  gas  fumes, 
heat,  eye  strain  from  bright  and  flashing  lights.  Finishing  processes:  gas 
and  solder  fumes,  wood  alcohol,  some  eye  strain,  troublesome  calluses  of 
hands,  caused  by  the  use  of  wire  cutters.  Amyl  acetate  is  used  in  some 
establishments  as  a  lacquer. 

Bronze  Powder. — The  manufacture  of  gold,  silver,  bronze  and  copper 
powder  is  attended  with  the  evolution  of  considerable  quantities  of  very  fine 
dust  even  though  the  process  of  grinding,  powdering  and  drying  is  carried 
on  in  inclosed  machinery. 

The  ordinary  gold  bronze  powder  is  composed  of  copper  and  zinc,  with 
traces  of  lead,  tin,  arsenic  and  iron.  Simon  and  Knyvett^  call  attention 
32 


498        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

to  the  possibility  of  lead  poisoning  because  in  a  case  brought  to  their  notice 
the  bronzing  powder  contained  7  per  cent,  of  lead.  Popoff,  cited  by  Casa- 
major/"  described  a  case  of  general  muscular  atrophy  and  gastro-enteric  symp- 
toms in  a  bronze  worker  which  he  attributed  to  zinc  poisoning.  Quite  a 
number  of  persons  engaged  in  handling  bronzing  powder  complain  of  a 
coppery  taste  in  the  mouth,  but  not  many  cases  of  plumbism  have  been 
reported.  Catarrhal  affections  of  the  eyes  and  respiratory  passages,  head- 
ache, and  gastric  derangements  are  not  infrequent  and  Oliver^"^  refers  to  the 
process  of  "dry  bronzing"  as  a  cause  of  inflammatory  conditions  of  the  skin. 
On  the  other  hand,  Wollner^^  maintains  that  the  bronze  workers  at  Fiirth 
are  a  comparatively  healthy  class.  Bronzes  are  often  suspended  in  benzene, 
acetone,  pyroxylin,  wood  alcohol,  amyl  acetate,  etc.,  with  consequent 
menace  to  healths.     (See  also  pages  614  and  677.) 

Gilds. — -Analyses  by  the  Ohio  State  Hygienic  Laboratories^*  of  six  leaf 
gilds  (gold,  silver,  copper,  aluminum  and  white  finish)  made  by  several 
manufacturers  failed  to  show  the  presence  of  either  lead  or  arsenic. 

Workers  in  Junk.— In  a  number  of  cities  special  establishments  exist 
where  the  process  of  sorting  rags,  paper  and  metal  is  carried  on  in  large 
sheds  and  warehouses,  and  where  the  non-ferrous  metals  are  melted  down. 
The  various  processes  are  usually  carried  on  under  the  most  insanitary  con- 
ditions and  are  doubtless  inimical  to  health.  Hayhurst  in  his  Ohio  Survey 
reports  four  cases  of  lead  poisoning  and  also  believes  there  is  considerable  risk 
from  brass  or  zinc  poisoning  where  some  of  the  soft  metal  alloys  are  handled 
and  melted.  He  also  reports  that  several  cases  of  lock  jaw  had  come  from 
one  of  the  large  plants. 

Mortality  Rates. — ^The  death  rate  from  tuberculosis  among  brass  workers 
is  twice  that  of  iron  and  steel  workers.^  Of  201  brass  workers,  31.3  per  cent, 
died  of  pulmonary  tuberculosis,  9.4  per  cent,  of  Bright's  disease,  9.0  per  cent, 
of  pneumonia,  8.4  per  cent,  of  cancer,  8.0  per  cent,  of  accidents.  Hoffman's 
figures^  for  1897  to  1906  cover  414  deaths:  consumption 38.9 per  cent.,  Bright's 
disease  9.9  per  cent.,  pneumonia  8.7  per  cent.,  heart  disease  6.5  per  cent., 
accidents  4.6  per  cent.  Hoffman  says,  "The  proportional  mortahty  from 
this  disease  (consumption)  was  excessive  at  all  ages  under  65,  but  most  so 
at  15  to  24,  when  out  of  every  100  deaths  from  all  causes  59.1  per  cent,  were 
from  consumption,  against  a  normal  expected  proportion  of  27.8  per  cent." 
Insurance  risks  on  brass  founders,  molders  and  casters  are  about  12  per 
cent,  higher  than  normal.  Those  in  finishing  processes,  including  grinders 
and  polishers,  have  more  privileges  or  are  not  discriminated  against  at  all. 

COPPER  INDUSTRIES 

Mining.  *—C(j/>/>er  miners  and  those  who  handle  ores,  as  at  milling,  are 
liable  to  arsenic  poisoning  and  also  plumbism,  providing  lead  is  present  in  a 

*  Prepared  by  K.  R.' irayhurst,  roluniI)us,  Oliio. 


EXPOSURE    TO    OCCUPATIONAL   INTOXICATIONS 


499 


soluble  form.  The  ore  dust  itself  produces  digestive,  respiratory,  skin  and 
conjunctival  disease.  Miner^s  boils,^^  occurring  in  Michigan  mines,  are  prob- 
ably due  to  the  action  of  the  hard  alkahne  character  of  the  water  upon  the 
skin,  thus  predisposing  to  infection.  Miner's  cramps  occur  especially 
among  trammers  in  deep  mines,  and  appear  to  be  due  to  heat-fatigue  toxins. 
These  cramps  may  involve  the  whole  body,  last  for  hours  or  days,  and 
perhaps  end  fatally.  The  exhaustive  character  of  work  in  connection  with 
one-man  drills^^  is  a  recent  factor  of  complaint  on  the  part  of  copper  miners. 


'-%    *  '-fi^^  iHiiii^ 

•^ ' 

-^Hlft 

■^  '^ 

..;''• '^^1          •    ' 

')m||^^^K              _.dM^ft 

%| 

■'■ 

Fig.  36. — Copper  mining.     Compressed-air  gang  at  work  on  face  of  ore,  Butte,  ^lontana. 
(Photo  furnished  Wiirdemann  by  Dr.  Donovan,  j 


Rook-worm  disease  is  a  great  factor  in  older  mines,  or  where  foreigners  are 
employed  (including  Cornishmen),  or  where  temperatures  reach  over  7o°F. 
In  California  mines  50  to  80  per  cent,  are  so  affected  with  a  loss  in  efficiency 
conservatively  estimated  at  20  per  cent,  of  the  working  force.  ^^  According 
to  Hoffman,^®  mortality  rates  among  copper  miners  for  191 1  ranged  from 
3.32  to  3.64  per  thousand,  with  tuberculosis  claiming  about  one-third  of  the 
deaths,  and  accidents  a  close  second.  Metal  miners  and  smelterers  are 
declined  or  considered  hazards  in  life  insurance.  ^^  (For  discussion  of  Copper 
Poisoning  see  Part  I.) 


500        ETIOLOGY   AND    PR0PHYL.4XIS    OF   OCCUPATIONAL  DISEASES 

Smelting. *-r-The  smelting  of  the  ore  is  carried  on  in  reverberatory  fur- 
naces and  involves  exposure  to  sulphurous  and  possibly  arsenical -fumes,  and 
also  to  the  products  of  combustion  which  sometimes  contain  25  per  cent, 
of  carbon  monoxide.  In  the  electrolytic  process  of  copper  refining  there 
is  exposure  to  acid  fumes.  Hard  work,  exposure  to  excessive  heat  and 
sudden  changes  are  likewise  injurious  factors  and  help  to  account  for  the 
pale  and  ill-nourished  condition  of  the  workers. 

In  most  of  the  modern  smelters  steps  are  taken  to  utilize  the  monoxide 
of  carbon  for  fuel,  and  the  sulphurous  fumes  are  condensed  in  leaden  chambers 
for  the  purpose  of  making  sulphuric  acid. 

(For  a  full  discussion  of  copper  fumes  see  page  16.) 

Preventive  Measures. — The  dangers  incident  to  the  smelting  operation 
can  be  materially  diminished  in  this  as  in  all  other  similar  processes  by 
high  stacks  and  well-constructed  furnaces,  proper  ventilation  and  sprink- 
ling of  the  flues  and  chambers  before  they  are  cleaned  out  and  the  employ- 
ment of  respirators  by  the  men  engaged  in  this  work.  It  is  equally 
important  that  during  the  pouring  of  the  metal  the  employees  should  be 
protected  from  the  toxic  fumes  by  hooded  exhaust  ventilation  and  suitable 
respirators. 

Coppersmiths,  etc. — Copper  workers  show  a  high  mortality  from  dis- 
eases of  the  respiratory  organs  and  the  consumption  rate  in  Great  Britain, 
according  ot  Dr.  Tatham,^*  is  59  per  cent,  in  excess  of  the  average.  The 
mortahty  from  diseases  of  the  circulatory,  digestive  and  urinary  system  is 
also  greatly  in  excess  of  the  average  among  other  metal  workers. 

The  men  employed  in  the  manufacture  of  copper  cornices,  tubing, 
utensils,  ornaments,  etc.,  especially  those  engaged  in  filing,  grinding,  turn- 
ing and  polishing,  are  more  or  less  exposed  to  the  inhalation  of  copper  dust 
and  metallic  oxides,  and  likewise  to  the  dust  from  emery  and  polishing 
wheels.  Quite  a  number  of  the  workers  show  a  green  discoloration  of  the 
gums,  teeth  and  hair,  and  the  characteristic  green  stain  of  the  underwear 
from  the  perspiration.  Some  dentists  have  reported  a  peculiar  purple 
color  and  swelling  of  the  gums  with  more  or  less  stomatitis,  in  copper  workers. 
Arlidge  and  Blaudet'^  have  held  for  a  long  time  that  the  copper  workers  are 
liable  to  a  specific  intoxication,  characterized  by  colic,  vomiting  and  purging. 
Dr.  Simon^**  admits  the  possibility  of  such  effects  in  men,  who  by  reason  of 
unclean  habits  are  liable  to  swallow  copper  dust  with  their  food,  especially 
those  who  work  in  old  copper  and  brass  covered  with  more  or  less  copper 
carbonates. 

Zadek^^  on  the  other  hand  cites  a  number  of  authorities  to  support  the 
opinion  that  copper  itself  is  not  a  toxic  agent,  and  that  the  symptoms, 
such  as  colic,  etc.,  are  caused  by  alloys,  chiefly  lead,  and  that  the  green 
discoloration  of  the  teeth  and  hair  has  no  pathological  significance.  Leurin,^'' 
while  questioning  the  possibility  of  chronic  copper  poisoning,  concludes  that 

*  Prepared  by  George  M.  Kober. 


EXPOSURE    TO    OCCUPATIONAL   INTOXICATIONS  50I 

acute  intoxications  may  occur  after  ingestion  of  considerable  quantities 
of  the  metal. 

Animal  experimentation,  conducted  by  Baum  and  Seeliger^^  would  appear 
to  establish,  however,  the  possibility  of  chronic  copper  poisoning.  Acute 
bronchial  catarrh,  rheumatism,  gastro-enteric  catarrh,  tonsillitis,  neuralgia, 
eczema,  diseases  of  the  veins,  contusions,  fractures,  burns  and  wounds  and 
lead  poisoning  are  prevalent  afifections  among  the  coppersmiths  of  Berlin. 
The  average  age  of  the  time  of  death  was  47.4  years. ^^  Coppersmiths,  like 
boiler  makers,  are  liable  to  develop  progressive  deafness.  Cases  of  oxalic 
acid  poisoning  contracted  during  the  polishing  of  copper  or  brass  utensils 
have  been  reported.  The  men  engaged  in  soldering  of  copper  are  exposed 
to  lead  and  the  inhalation  of  acid  and  possibly  arseniureted  hydrogen, 
fumes.  Copper  is  also  used,  in  connection  with  gold,  silver  and  mercury, 
in  water  gilding  and  in  the  manufacture  of  bronzing  powder.  The  sulphate 
of  copper  is  used  for  coppering  wire.  Many  of  these  processes  involve 
not  only  the  inhalation  of  dust,  but  also  of  acid  fumes  and  therefore  engender 
diseases  of  the  respiratory  and  digestive  organs. 

Preventive  Measures. — Much  of  the  danger  of  dust  inhalation  has  been 
eliminated  by  the  substitution  of  acid  dips  for  polishing  but  the  acid  dipping 
solutions  expose  the  operatives  to  the  inhalation  of  irritating  fumes  and 
hence  all  operations  involving  the  evolution  of  dust  or  fumes  should  be  carried 
on  with  adequate  provisions  for  hood  and  exhaust  ventilation. 

ZINC  INDUSTRIES* 

Mining. — Zinc  miners  are  liable  to  arsenic  and  "metallic"  poisoning,^' 
and,  where  the  ores  contain  manganese,  those  exposed  to  the  dust  have 
developed  peculiar  nervous  symptoms. ^^  American  miners  are  very  little 
liable  to  lead  poisoning  in  connection  with  zinc  mining  and  ore  milUng, 
since  the  lead  is  in  the  insoluble  form,  as  a  rule.^^ 

Smelting. — American  ores  are  usually  smelted  by  the  Belgian  process 
in  which  the  ore  is  first  roasted  to  drive  ofif  the  sulphur  (sulphuric  acid  is  an 
important  by-product),  then  volatilized  in  clay  retorts  having  muffles 
attached  in  which  the  fumes  condense.  The  escape  of  zinc  fumes  which 
sometimes  contains  also  the  fumes  of  antimony,  arsenic,  cadmium,  lead  and 
manganese  is  rendered  almost  negligible.  Zinc  smelting  has  certain  forms 
of  occupational  complaints:  (i)  "zinc  chills"  (see  Part  I)  which  are  of  in- 
frequent occurrence  because  from  industrial  economy  the  escape  of  fumes  is 
limited;  (2)  lead  poisoning,  where  leadoccurs  in  the  ores,  is  of  greater  frequency 
than  among  brass  moulders  (the  lead  burners  or  solderers  who  work  in  the  acid 
tank  houses  are  also  very  Uable  to  plumbism);  (3)  "summer  colics,"  probably 
due  to  heat-fatigue  toxins,  plus  the  drinking  of  cold  water;  (4)  heat  prostra- 
tions; (5)  "zinc  asthma,"  which  is  very  prevalent  and  shows  winter  exacerba- 

*  Prepared  by  E.  R.  Hayhurst,  Columbus,  Ohio. 


S02         ETIOLOGY    AND    PROPHYLAXIS    OF    OCCLTATIONAL   DISEASES 

tions;  (6)  gas  poisoning,  from  the  producer-gas  used;  (7)  industrial  alcoholism, 
due  to  a  tradition  among  the  workers  that  alcohoHc  liquors  are  antidotal 
to  zinc  and  other  metallic  poisonings,  but  heat,  dust,  gases  and  fatigue  also 
contribute  to  it;  (8)  rheumatic  affections — very  common — especially  lum- 
bago; (9)  dermatitis  and  boils,  due  to  the  ore  dusts;  (10)  a  rare  possibility 
of  arsenic  poisoning,  in  the  American  works;  and  (11)  night  bhndness,^^ 
probably  a  zinc  effect,  but  may  be  due  to  looking  at  zinc  flames.  It  con- 
tributes to  accidents.     Colored  glasses  should  be  worn  by  furnacemen. 

Rambousek's"  summary  of  the  afflictions  of  zinc  smelter  workers  shows 
that  among  4789  men  there  were  50  cases  of  lead  cohc,  18  of  kidney  diseases, 
223  of  gastric  and  intestinal  catarrh,  40  of  anaemia,  and  612  of  rheumatism 
in  I  year's  time.  (For  insurance  risks  see  page  499,  under  copper.) 
According  to  Dr.  Krautz^^  the  number  of  cases  of  lead  poisoning  in  the  German 
zinc-smelting  industry  has  been  reduced  by  hygienic  methods  from  819  cases 
among  1200  employees  in  1879-1885  to  78  cases  per  6400  workers  in  1910. 

Zinc  is  extensively  employed  in  sheet  metal  for  many  purposes,  and  it  is 
an  important  constituent  of  brass.  It  is  also  used  in  the  galvanizing  process 
of  sheet  iron,  wire,  etc.,  and  in  the  manufacture  of  zinc  oxide  and  other  zinc 
salts.  According  to  Tatham  the  mortality  of  zinc  workers  in  Great  Britain 
was  1 198,  as  against  602  for  agriculturists.  Consumption  and  diseases  of 
the  respiratory  and  circulatory  organs  predominate. 

Galvanizing. — Sheet  iron  or  metal  to  be  galvanized  is  first  cleansed  in 
a  "pickling"  bath  of  hot  dilute  mineral  acid,  and  then  dipped  into  a  bath  of 
molten  zinc,  which  is  kept  from  overheating  by  sprinkling  sal  ammoniac 
upon  its  surface.  A  layer  of  melted  lead  forms  the  bottom  of  the  zinc  bath, 
its  heavier  specific  gravity  keeping  it  down,  where  it  helps  to  prevent  over- 
heating. The  occupational  afflictions  of  this  industry  may  be  summed  up 
as  follows:  (i)  Inhalation  of  acidic  steam  and  vapor  from  pickling,  causing 
rhinitis,  frontal  headaches,  conjunctivitis,  bronchitis,  and  asthma,  dental 
caries,  reddening  and  softening  of  the  gums,  hyperacidity,  mucous  gastritis, 
and  attendant  disturbances,  also  the  immersion  of  the  hands  in  acid 
baths  whitens  and  hardens  the  skin  which  tends  to  crack;  (2)  sal  ammoniac 
"smoke,"  when  inhaled,  at  first  causes  coryza,  with  perhaps  epistaxis,  nasal 
sores  and  dyspnoea,  but  workmen  become  rapidly  inured  to  it;  (3)  rheumatism 
and  lumbago,  from  alternations  of  heat  and  cold  exposures,  especially  when 
combined  with  occasional  heavy  lifting  or  straining;  (4)  dermatitis,  from  the 
chemicals  used;  (5)  arsenic  poisoning  as  a  rare  possibility,  from  the  spelter; 
(6)  "zinc  chills "^^  (see  Part  I),  which  can  occur  only  when  the  metal  becomes 
overheated;  and  (7)  lead  poisoning,  infrequently  and  probably  due  to  handling 
the  metal  rather  than  from  any  escape  of  lead  as  fumes. 

Manufacture  of  Zinc  Oxide. — Ores  of  second  grade,  as  a  rule,  are 
smelted  and  the  zinc  fumes  condensed  in  long  air-cooled  pipes  under  nega- 
tive pressure,  which  convey  the  zinc  oxide  formed  to  bag  houses.  Here  the 
oxidized  coal  gases  and  other  gases  escape  through  the  meshes  of  the  muslin 


EXPOSURE  TO  OCCUPATIONAL  INTOXICATIONS  503 

bags,  while  the  flaky  oxide  is  caught.  The  afflictions  of  the  furnacemen 
are  practically  the  same  as  those  of  smelterers,  but  zinc  chills  (see  Part  I) 
are  less  common  because  of  less  exposure.  However,  they  may  occur.'" 
Bassett'^  states  that  they  have  been  a  very  serious  factor  in  securing  and 
retaining  labor,  particularly  in  the  bag  rooms.  This  is  entirely  a  question  of 
the  completeness  of  the  oxidation  and  the  cooling  of  the  oxide  before  it  reaches 
the  bags.  In  the  new  and  model  plant  which  I  recently  visited  at  Pal- 
merton,  Pa.,  bronchial  afflictions  were  said  to  be  the  only  complaint  among 
the  bagmen,  this  from  the  escaped  dust.  Packers  were  more  troubled 
even  than  bag-house  men.^^  Zinc  dust  (pulverized  zijic)  and  zinc  oxide 
may  also  produce  dermatitis,  conjunctival  and  digestive  disturbances,  simi- 
lar to  other  metallic  dusts,  and  workmen  should  be  protected  as  well  as 
possible.  Zinc  dust  may  be  a  constituent  of  "bronze"  powders.  Zinc 
oxide  may  be  used  in  brewing  to  assist  in  disinfection  and  preservation. 
Zinc  white  (zinc  oxide)  is  used  in  great  quantities  to  mix  with  dried  rubber 
to  secure  the  physical  properties  necessary  for  pneumatic  tire  casings. 
Zinc  white  and  lUJiopone  (the  latter  is  zinc  sulphide  and  barium  sulphate) 
are  the  best  substitutes  for  lead  in  paint.  Lithopone  makes  an  excellent 
marine  paint.  Sir  Thomas  Oliver^^  says  that  zinc  can  certainly  be  used  for 
all  interior  decorations,  and  that  reformers  maintain  that  the  slight  ad- 
vantage of  white  lead  over  zinc  for  exterior  painting  is  not  worth  the  cost 
to  human  life. 

Robinson  and  Wilson^^  inspected  eight  brass  and  copper  establishments 
in  Cincinnati  and  examined  2072  workers  inclusive  of  142  females  and  found 
17  cases  of  tuberculosis  or  0.88  per  cent,  among  the  male  workers  and  none 
among  the  females.  This  is  a  very  much  lower  rate  than  in  certain  other 
industries.  Sand  blasting,  grinding,  buffing  and  polishing  were  extremely 
dusty  processes  before  the  installation  of  the  exhaust  system,  and  this  hazard 
has  not  yet  entirely  been  eliminated. 

The  investigators  comment  favorably  upon  the  sanitary  conditions  in 
the  larger  plants,  but  this  cannot  be  said  of  all  the  estabUshments,  as  they 
received  a  letter  from  an  employee  in  a  brass  factory  to  which  admission  was 
refused,  requesting  an  investigation,  and  stating  that  the  men  are  often  over- 
come by  the  fumes  in  the  melting  department. 

BIBLIOGRAPHY 

'  U.  S.  Cens.  Mort.  Stat.,  1909. 

2.  Published  tables. 

'.Sharp. — Modern  Foundry  Practice,  1900,  632. 

\Rambousek. — Industrial  Poisoning.     Trans,  by  Legge,  1913,  323. 

\Frey. — Vrtljschr.  f.  gerichtl.  Med.  Berl.,  1912,  3,  F.,  XLIII,  i,  S.  H.,  113-141. 

^  Neisser-Internationale  tjbersicht,  etc.,  1907,  page  17. 

'  Report  of  Sanitary  Inspectors,  Mass.,  1909,  page  41. 

*  British  Medical  Journal,  June  2,  1910. 

^Oliver's  Dangerous  Trades,  1902,  page  468. 


504        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

10  Transactions  15th  Intern.  Congress  on  Hygiene,  Wash.,  D.  C,  1913,  Vol.  Ill,  Part  II, 

page  578. 
"  Oliver's  Dangerous  Trades,  1902,  page  268.     Industrial  Lead  Poisoning  in  Europe.    Bull. 

Bureau  of  Labor,  Washington,  D.  C,  No.  95,  July  11,  1911,  page  83. 
12  Wollner. — Verl.  d.  Naturforschervereins,  Niirnberg,  1893,  II,  2,  page  426. 
"  Warthin. — Public  Health,  Michigan,  ist  qt.,  191 2,  67. 
"Taylor. — The  Survey,  Nov.  i,  1913,  131- 
1*  Gunn. — Jr.  Am.  Med.  Assoc,  Jan.  28,  1911,  259. 
"  E.xhibits  of  the  Prudent.  Ins.  Co.,  Sept.,  191 2. 
1^  Prudent.  Ins.  Co.  Rate  Book,  June,  1912.     See  also  National  Union,  June,  1912,  III, 

No.  2,  4-6. 
"  Tatham. — Oliver's  Dangerous  Trades,  London,  1902. 
i»  Zadek. — Weyl's  Handbuch  d.  Gewerbekrankheiten,  1908,  page  112. 
2"  Deutsche  Med.  Wochenschft.,  1901,  page  689. 

^^  Archiv  f.  wissenschaftl.  u.  praktische  Tierheilkunde,  Vol.  XXIII,  6,  1897. 
"  Zadek. — Weyl's  Handbuch  der  Gewerbekrankh.,  1908,  page  149. 
"  Murgia. — La.  Clin.  Mod.,  1906,  XII,  316-319. 

"  Casamajor. — Fifteenth  Int.  Cong,  on  Hyg.  and  Dem.,  Ill,  Pt.  2,  574. 
*5  Mangold,  G.  B. — Cited  from  The  Survey,  Jan.  17,  1914,  470.     See  also  U.  S.  Labor 

Bulletin  No.  95,  page  3. 
2®  Roth. — Komp.  der  Gewerbekr.,  1909.     See  also  Laureck,  in  Weyl's  Handbuch. 
2^  Industrial  Poisoning.     Trans,  by  Legge,  1913,  130. 
"  Krautz. — Sozial  Technik,  IV,  No.  2,  191 2. 
23  The  author  has  encountered  a  number  of  such  cases. 

^^  Bouchut. — Cited  from  Arlidge's  Diseases  of  Occupation,  1892, 449,     Also  Hohmann,  1903. 
^^  Jr.  of  Ind.  and  Eng.  Chem.,  March,  191 2,  154. 
'2  Dr.  Luther,  Company  Surgeon. 
''  The  Survey,  Aug.  30,  1913,  662. 
^^  Ohio  Public  Health  Journal,  August,  19 15,  170. 
35  Robinson,  D.  E.,  and  Wilson,  J.  G.— U.  S.  Public  Health  Bulletin  No.  73,  March,  1916. 


SECTION  III 

PROCESSES    INVOLVING    EXPOSURE    TO    CARBON   BISULPHIDE 
AND  THE  INTOXICATIONS  IN  THE  INDIA-RUBBER  INDUSTRY 

BY  E.  R.  HAYHURST,  M.  D.  AND  GEORGE  M.  KOBER,  M.  D. 

Rubber  Washing.  Compounding.  IMi.xing  Mills.  Calendering  and  Warming  Mills. 
Tire  Building.  Buffing.  Dipping.  Manufacture  of  Rubber  Mechanical  Goods, 
Drug  Sundries,  Accessories,  etc.  Steam  and  Vapor  Vulcanizing.  Cold  Vulcaniz- 
ing. Rubber  Cement  Manufacture  Rubber  Reclaiming.  Manufacture  of  Rub- 
ber Substitutes.     Preventive  measures. 

THE  INDIA  RUBBER  INDUSTRY 

This  industry  includes  all  establishments  in  which  waterproof  garments, 
boots,  shoes,  rubber  gloves,  water  bags,  ice-caps,  surgical  appliances,  chil- 
dren's toys,  rubber  tires,  door  mats  and  any  other  rubber  goods  are  made. 

India  rubber  is  the  inspissated  juice  of  various  rubber  plants,  and  is  known 
as  caoutchouc.  This  is  insoluble  in  water,  but  quite  soluble  in  ether,  acetone, 
petroleum  benzine,  benzene,  bisulphide  of  carbon  and  turpentine. 

Benzine  is  most  frequently  used  as  a  solvent  and  serves  to  convert  the 
rubber  into  a  doughy  mass,  with  which  other  materials  such  as  white  lead, 
zinc  oxide,  chalk,  litharge,  cinnabar,  graphite,  powdered  soapstone,  etc.,  are 
mixed. 

Cases  of  lead  poisoning  may  occur  from  the  use  of  litharge  or  other  lead 
compounds.  Of  162  cases  of  lead  poisoning  treated  in  the  Massachusetts 
General  Hospital  Dispensary,  18,  or  1 1  per  cent.,  were  among  rubber  workers.^ 
Of  544  cases  of  lead  poisoning  reported  by  Hayhurst-  in  the  Ohio  Survey,  43 
occurred  in  the  rubber  industry. 

Cinnabar  and  antimony  are  among  the  red  coloring  agents  used  in  the 
manufacture  of  rubber  goods.  Roth^  refers  to  the  fact  that  French  authors 
some  years  ago  called  attention  to  a  peculiar  "  caoutchouc  disease  "  which  they 
attributed  to  the  cinnabar  contained  in  the  gutta-percha  plates  of  artificial 
teeth.  Oliver^  cites  the  observation  of  Lazarus,  a  German  dentist,  who  re- 
ported 20  cases  of  dental  caries  in  gutta-percha  workers,  complicated  in  some 
instances  with  necrosis  of  the  jaw  bone,  but  oflfered  no  explanation  as  to  the 
probable  cause. 

The  rubber  industry  is  a  very  important  one  in  the  State  of  Ohio,  and 
Hayhurst  found  the  chief  poisons  employed,  in  the  order  of  their  danger  tOj 
users,  as  follows:  aniline  oil,  carbon  bisulphide,  benzol,  lead  and  antimonyj 
compounds,  mineral  acids,  alkalis,  benzine  (naphtha,  petrol,  gasoline)  wood 
alcohol,  sulphur  chloride,  carbon  tetrachloride,  mercuric  sulphide  and  turpen- , 

505  i 


5o6        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

tine.  In  some  of  the  processes  there  was  an  additional  risk  from  exposure 
to  illuminating  and  fuel  gas.  The  following  is  a  summary  of  Hayhurst's 
exhaustive  report  of  the  different  processes  involving  special  hazards. 

1.  Rubber  Washing.— This  process  deals  with  the  cleaning  and  prepara- 
tion of  the  crude  rubber,  such  as  cracking  it  up  in  mills,  washing  it  in  cold 
and  warm  running  water  and  subsequent  steeping  in  large  tanks  of  water. 
This  process  involves  wet  and  sloppy  work  and  exposure  to  a  steamy  atmos- 
phere. In  some  of  the  plants  lead  and  antimony  were  used  in  dust  form  in 
the  same  room,  although  quite  foreign  to  this  particular  process,  and  with 
considerable  liability  to  poisoning  all  the  workers. 

2.  Rubber  Compounding. — In  this  department  the  various  dry  ingredients 
which  go  into  the  rubber,  such  as  metallic  oxides  and  salts  (Al,  Fe,  Ca,  Sn, 
Zn,  Pb,  Sb),  soapstone,  etc.,  are  scooped  from  bins  according  to  various  for- 
mulas, weighed  by  hand,  placed  in  open  top  tin  boxes,  and  carried  direct  to 
the  mixing  mills  or  deHvered  close  thereto  through  pipes,  there  to  be  incor- 
porated with  the  rubber.  Occasionally  the  ingredients  are  first  bolted  in 
shakers  to  break  up  lumps,  which  is  an  exceedingly  dusty  process  unless  the 
shaker  is  well  inclosed.  The  work  also  involves  exposure  to  lead  and 
antimony  dust,  and  to  the  fumes  of  aniline  oil,  which  is  often  poured  directly 
upon  the  weighed  powders  from  an  ordinary  cup.  In  the  Ohio  Survey  22  cases 
of  positive  and  5  cases  of  tentative  lead  poisoning  were  observed  among  the 
151  wage  earners  employed  in  this  process.  Two  cases  of  acute  aniline 
poisoning  were  reported,  but  had  not  been  seen  by  the  investigator.  Hay- 
hurst  believes  that  the  workmen  in  this  department  should  be  subject  to  care- 
ful supervision,  monthly  medical  inspections,  and  feels  confident  that  the 
work  could  be  rendered  practically  dustless,  by  competent  ventilating 
engineers. 

3.  Rubber  Mixing  Mills. — In  this  process  the  washed  and  dried  rubber  is 
macerated  between  steel  rollers,  and  mixed  with  the  compounds  referred 
to  in  paragraph  2.  In  spite  of  hoods  and  exhaust  flues,  even  when  present, 
more  or  less  dust  escapes  while  the  injurious  ingredients  are  scooped  out  of  the 
conveyance  boxes  and  poured  by  hand  upon  the  rolls.  The  amount  of  lead 
dust  is  estimated  by  the  Ohio  Survey  as  high  as  25  per  cent.,  and  the  odors 
from  aniline  oil  and  of  antimony  fumes  were  plainly  detectable  in  several 
establishments.  The  investigators  discovered  22  positive  cases  and  4 
tentative  cases  of  lead  poisoning,-  and  3  positive  cases  of  aniline  poisoning, 
among  252  male  wage  earners.  The  risks  of  poisoning  were  considered  bad  in 
13  out  of  21  establishments  because  of  lack  of  adequate  ventilation  for  the 
removal  of  dust  and  fumes,  lack  of  medical  supervision  and  instructions,  and 
hence  ignorance  on  the  part  of  the  workers,  many  of  whom  were  wearing 
mustaches  and  eating  and  chewing  while  at  work;  there  was  also  lack  of 
personal  care  and  of  adequate  washing  facilities. 

4.  Rubber  Calendering  and  Warming  Mills. — In  this  process  the  com- 
pounded material  brought  from  the  mixing  mills  is  placed  into  the  rollers  of 


EXPOSURE  TO  OCCUPATIONAL  INTOXICATIONS  507 

the  warming  mills  and  of  the  calenders,  which  perfect  and  grade  down  the 
material  into  sheets  of  required  thickness.  The  calenders  are  also  used  to 
spread  and  press  the  rubber  mass  over  the  fabric  to  be  waterproofed,  which 
process  is  called  "frictioning."  When  this  process  is  carried  on  in  the  same 
room  with  the  mixing  mills  the  danger  from  poisonous  dust  inhalation  is 
quite  great.  But  even  when  completely  separated  there  is  more  or  less  soap- 
stone  dust,  which  is  freely  used  in  the  handling  and  packing  of  the  finished 
goods.  The  heat  from  the  rollers  is  apt  to  be  excessive,  unless  guarded  against 
by  adequate  exhaust  ventilation.  Other  occupational  risks  are  exposure  to 
benzine  vapors  especially  from  open  cement  cans.  In  the  Ohio  Survey  no 
cases  of  occupational  poisoning  were  observed  in  this  process,  although  in 
only  three  places  were  all  the  workers  healthy  appearing. 

5.  Rubber-tire  Building. — In  the  manufacture  of  casings  for  auto- 
mobile and  bicycle  tires  different  layers  of  rubber  fabric  are  applied  upon 
wheel-shaped  moulds  by  workers  who  are  seated  before  them,  and  when  thus 
built  up  by  hand  or  machine  labor,  the  beads,  cover  layers,  etc.,  are  finally 
attached  by  means  of  rubber  cement  and  pressure.  In  this  process  benzine 
is  freely  used  with  the  sponge  and  also  as  a  solvent  for  the  cement.  In 
9  of  the  13  establishments  investigated  in  Ohio,  the  odor  from  benzine  was 
strong  enough  to  cause  symptoms.  Nine  cases  of  benzine  poisoning  in 
female  workers  in  a  rubber-tire  factory  at  Upsala  were  reported,  of  whom 
four  died.  The  history  does  not  make  clear  that  they  were  cases  of  pe- 
troleum benzine  or  of  benzene  poisoning.^ 

The  chief  complaints  in  the  Ohio  Survey  were  headache,  dizziness  and 
stupefaction.  Antimony  dermatitis  was  an  occasional  complaint.  Soap- 
stone  dust  was  present  in  variable  amounts  in  all  places.  The  effects  of 
fatigue  as  a  result  of  speeding  up,  faulty  positions,  jarring  processes,  pressure 
against  the  body  and  lifting  and  carrying  of  heavy  moulds  were  evident 
in  most  places.  In  winter  the  effect  of  cold  drafts  on  sedentary  workers 
from  windows  kept  open  to  drive  out  the  fumes  was  an  objectionable  feature. 

The  inner  tubes  for  rubber  tires  are  made  by  lapping  long  strips  of  almost 
pure  rubber  around  an  iron  rod  of  suitable  size,  or  by  butting  the  edges 
together  on  a  table  top.  The  rubber  is  made  to  adhere  to  itself  by  mois- 
tening with  benzine  or  rubber  cement.  The  long  tube  is  next  wrapped  with 
a  wet  strip  of  cloth  and  then  steam  cured,  after  which  the  ends  are  spliced 
together,  as  a  rule,  by  a  cold-cure  process.  •  This  work  is  performed  to  a  great 
extent  by  youthful  men  and  women  and  involves  considerable  standing  and 
walking  to  and  fro,  but  the  chief  hazards  are  exposure  to  benzine  and  soap- 
stone  dust.  Benzine  stupor  and  fainting  spells  were  common,  especially 
among  females  and  recent  employees. 

Copious  ventilation,  a  room  temperature  not  exceeding  68°,  and  the 
substitution  of  closed  containers  with  a  pressure-valve  benzine  emitter,  in 
place  of  the  open  cups  now  used,  would  greatly  diminish  the  dangers  from 
benzine  fumes. 


5o8        ETIOLOGY   AND    PROPHYL.\XIS   OF    OCCUPATIONAL   DISEASES 

6.  Rubber  BuflSng.— The  process  of  buffing  rubber-tire  casings  is  done 
by  revolving  them  on  a  wheel  and  holding  a  coarse  file  against  them.  Other 
semi-hard  rubber  objects  are  buffed  by  means  of  emery  wheels.  The 
object  in  either  case  is  to  secure  a  rough  surface  for  the  cement,  in  order  to 
apply  additional  coats.  There  is  also  exposure  to  dust  during  the  grinding 
and  polishing  of  hard-rubber  goods. 

This  work,  apart  from  being  fatiguing  and  very  dusty  and  dirty  (workers 
look  like  coal  heavers),  involves  the  risk  of  lead  poisoning,  which  varies  in 
degree  with  the  amount  of  lead  contained  in  the  rubber  dust.  Benzine 
fumes  were  also  present  in  most  of  the  establishments  covered  by  the  Ohio 
Survey. 

7.  Rubber  Dipping. — In  this  process  moulds  of  gloves,  finger  cots,  etc., 
are  dipped  mechanically  into  vats  containing  a  solution  of  rubber  dissolved 
in  benzine.  Upon  raising  the  objects  from  the  vats,  a  thin  coating  of  rubber 
adheres  to  the  mould,  and  the  dipping  is  repeated  until  the  required  thick- 
ness is  secured.  The  process  involves  exposure  to  benzine  fumes  and  great 
precautions  are  necessary  to  avoid  fire  and  explosions.  Benzine  fumes,  from 
the  vats  and  dipping  frames  above,  constituted  a  bad  hazard  in  seven 
places  and  to  a  less  degree  in  four  establishments  covered  by  the  Ohio 
Survey.  The  benzine  tanks  should  be  covered  when  not  in  use,  the  floor 
should  be  latticed,  with  a  strong  exhaust  system  beneath  to  draw  off  the 
benzine  fumes,  and  the  entire  system  of  exhaust  ventilation  should  be  set 
in  motion  during  the  dipping  process. 

8.  Rubber  Mechanical  Goods,  Drug  Sundries,  Accessories,  Etc.— 
This  group  includes  the  manufacture  (assembhng  and  finishing)  of  a  great 
variety  of  soft-  and  hard-rubber  goods,  such  as  rubber  bands,  washers,  child- 
ren's toys  and  balloons,  water  bags,  ice-caps,  surgical  appliances,  drug 
sundries,  finishing  of  rubber  gloves,  assembling  of  boots,  waterproof  garments, 
door  mats,  fire  hose,  large  belts  for  power  transmission,  and  other  rubber 
fabrics.  The  Ohio  Survey  covered  22  estabUshments  with  2912  male  and 
1668  female  employees.  The  chief  health  risks  were  benzine  fumes  and 
soapstone  dust;  occasionally  also  benzol,  sulphur  chloride,  carbon  bisul- 
phide, ammonia,  aniline  dyes  and  wood  alcohol.  Benzine  vapors  are 
constantly  evolved,  but  are  especially  pronounced  when  rubber  solutions 
are  used  for  waterproofing,  in  the  joining  of  the  seams,  in  cementing  edges, 
laps  and  splices,  and  during  the  evaporation  of  naphtha  from  the  finished 
product,  which  is  done  over  steam  tables.  In  but  one  plant  were  all  em- 
ployees satisfactorily  protected  from  these  forms  of  industrial  poisoning. 
As  a  matter  of  fact,  10  cases  of  chronic  benzine  (and  perhaps  benzol) 
poisoning  were  seen  in  four  plants,  and  quite  a  number  of  the  employees, 
especially  females,  suffered  from  nausea,  dizziness,  faintness,  headaches, 
loss  of  appetite,  loss  of  weight,  tiredness,  "benzine  jags,"  eczema,  coughs 
and  colds.  Close  confinement  and  crowding  of  workers  are  often  observed. 
Sometimes  windows  are  not  permitted  to  be  opened  for  fear  of  air  effects, 


EXPOSURE    TO    OCCUPATIONAL   INTOXICATIONS  509 

but  there  is  no  consistency  about  this  and  the  recommendations  for  the 
removal  of  dust  and  fumes  already  referred  to  are  equally  indicated  in  this 
branch  of  the  rubber  industry. 

9.  Rubber  Vulcanizing. — All  rubber  goods,  in  order  to  withstand  the 
influence  of  changes  in  temperature,  and  to  retain  their  elasticity,  are 
vulcanized.     This  process  is  also  spoken  of  in  the  trade  as  "curing." 

Steam  Vulcanizing  of  Tire  Casings. — In  the  comparatively  harmless  or 
steam  process,  the  tire  casings  are  placed  in  iron  moulds  and  these  are  placed 
within  steam  cylinders  and  exposed  to  a  temperature  of  26o°F.  In  some 
plants  the  tires  are  steam-cured  when  partly  built  and  again  when  finished. 
There  are  no  special  poison  risks,  except  the  escape  of  fuel  gas  fumes  in  some 
plants,  but  soapstone  dust  and  the  exposure  to  high  temperature  and  humidity 
are  common  observations. 

Press  Rooms. — In  these  rooms  steam  vulcanizing  is  done  by  means  of 
steel  presses,  having  hollow  chambers  to  accommodate  the  various  shaped 
moulds  through  which  the  steam  passes.  The  rubber  goods,  such  as  water 
bags,  drug  sundries,  etc.,  are  placed  within  the  vulcanizers  for  from  15  to 
30  minutes.  Limited  amounts  of  sulphur  compounds,  such  as  chloride  of 
sulphur,  sulphide  of  barium,  calcium  or  antimony,  are  added  to  the  rubber 
goods. 

The  spfecial  hazards  observed  in  the  Ohio  Survey  were  benzine,  benzol  and 
occasionally  antimony  fumes  from  the  rubber.  Exposure  to  excessive  heat 
(i2o°F.)  humidity,  abrupt  changes  in  temperature,  and  considerable  quanti- 
ties of  soapstone  dust  are  mentioned  as  injurious  factors.  The  generous 
use  of  asbestos  coverings  to  the  presses  and  more  copious  room  ventilation 
are  recommended. 

Vapor  Vulcanizing. — In  this  process  the  rubber  goods,  such  as  rubber 
gloves,  finger  cots,  etc.,  are  exposed  to  the  vapors  of  sulphur  chloride,  placed 
upon  a  tin  in  a  warming  cupboard.  In  some  establishments,  carbon  tetra- 
chloride and  perhaps  carbon  bisulphide  are  used.  In  addition  to  exposure  to 
these  industrial  poisons,  there  may  also  be  exposure  to  benzine,  benzol  and 
soapstone  dust.  The  fumes  should  be  withdrawn  before  opening  or  enter- 
ing the  cupboards. 

Cold  Vulcanizing. — This  process,  also  known  in  the  trade  as  "cold  cure" 
and  "acid  cure,"  is  chiefly  used  for  joining  the  ends  of  inner  tubes  for  tires 
and  also  for  curing  pure  rubber  goods  and  is  quite  dangerous,  especially  when 
carbon  bisulphide  is  employed.  In  this  process  the  rubber  goods  are  passed 
through  a  solution  containing  usually  i :  1000  parts  of  carbon  bisulphide  and 
from  2: 10-1000  of  sulphur  chloride  and  subsequently  dried  in  cupboards  at  a 
temperature  of  about  io4°F.  Sometimes  the  solution  is  applied  with  a  brush 
or  sponge.  During  this  process  the  employees  are  exposed  not  only  to  the 
fumes  of  carbon  bisulphide  but  in  the  dipping  of  the  goods  also  to  absorption 
of  the  poison  by  the  skin.  This  poison  inflicts  special  damage  to  the  blood 
cells  and  general  nervous  system,  and  like  benzine  also  causes  a  dry  and 


5IO        ETIOLOGY    AND    PROPHYLAXIS    OF    OCCUPATIONAL    DISEASES 

harsh  condition  of  the  skin  of  the  hands  by  removal  of  the  natural  fat.     (See 
carbon  bisulphide,  pages  35,  725.) 

Laudenheimer^  has  collected  three  cases  of  mental  disturbances  and  19 
cases  of  diseases  of  the  nervous  system,  in  219  persons,  who  had  come  into 
contact  with  carbon  bisulphide,  and  his  comparative  statistics  show  that  these 
affections  are  much  more  prevalent  in  the  rubber  industry  than  in  the 
textile  industries. 

TheLeipsic  Psychiatric  Clinic'^  reported  50  cases  of  nervous  disorders  caused 
by  carbon  bisulphide  poisoning,  of  which  nearly  one-third  developed  insanity. 

The  present  tendency  is  to  replace  carbon  bisulphide  by  the  employ- 
ment of  chloride  of  sulphur  in  benzine,  which  is  at  least  a  less  dangerous  agent. 
As  a  substitute  for  benzine,  dichlorethane  and  carbon  tetrachloride  have 
been  urged.  Acetone,  turpentine  and  ether  are  also  employed  as  solvents 
instead  of  CS2,  benzine  and  benzene.^ 

The  Ohio  Survey  which  covered  the  "cold  cure"  process  in  15  establish- 
ments with  about  200  employees  revealed  exposure  to  benzine,  benzol,  wood 
alcohol,  carbon  bisulphide,  carbon  tetrachloride,  and  sulphur  chloride,  soap- 
stone  and  sulphur  dust.  A  number  of  cases  of  poisoning  were  diagnosed 
and  quite  a  number  of  pale  and  anaemic  persons  of  both  sexes  were  seen. 
Inflammatory  affections  of  the  skin,  cases  of  dyspepsia  and  neurasthenia 
were  frequent  observations. 

Von  Harmsen^  reports  that  of  220  German  vulcanizers,  18.6  per  cent, 
suffered  from  gastro-enteric  catarrh,  11.8  per  cent,  from  tonsillitis  and  catarrh 
of  the  pharynx,  6.8  per  cent,  from  anaemia  and  0.9  per  cent,  from  diseases  of 
the  nervous  system.  The  statistics  of  the  Sick  Benefit  Society  of  Leipsic 
show  a  very  high  morbidity  rate  in  the  rubber  industry,  viz.,  1028  days  per 
100  workers  per  annum,  and  a  mortality  hazard  of  0.90  per  cent.  The  same 
statistics  give  the  percentage  of  carbon  disulphide  poisoning  as  1.83,  including 
a  considerable  number  of  abortions  and  premature  births,  which  were  at- 
tributed to  mild  forms  of  acute  poisoning. 

10.  Rubber  Cement  Manufacture.— In  this  process,  the  powdered 
rubber  is  dissolved  by  means  of  benzine,  benzol  or  carbon  bisulphide,  either 
singly  or  combined  and  sometimes  other  ingredients  are  added.  The  mixing 
is  frequently  done  by  hand  labor  in  open  containers,  but  in  modern  estab- 
lishments the  process  is  carried  on  mechanically  and  the  poisonous  solutions 
and  fumes  are  confined  within  rotary  mixers,  and  the  rooms  are  supplied 
with  efficient  exhaust  ventilation.  The  filhng  of  cans  or  compressible  tubes 
with  cement  may  be  done  openly  or  within  a  confining  apparatus.  The 
process  involves  comparatively  few  employees  but  an  undue  exposure  to  the 
industrial  poisons  already  mentioned.  The  degree  of  danger  varies  with 
the  mechanical  protective  measures  provided  and  the  care  exercised  by  the 
individual  worker.  There  is  also  considerable  danger  from  fire  and  explosions, 
on  account  of  the  inflammable  character  of  the  vapors  present;  hence  isolated, 
unheated  out-buildings  are  often  used. 


EXPOSURE  TO  OCCUPATIONAL  INTOXICATIONS  51I 

11.  Rubber  Reclaiming. — This  is  a  special  industry  for  the  purpose  of 
reclaiming  rubber  from  waste  products  and  old  rubber  goods.  The  process 
consists  in  grinding,  milling,  chemical  treatments  and  drying,  and  the  product 
is  generally  known  as  "rubber  shoddy."  In  addition  to  the  rubber  solvents 
already  mentioned,  mineral  acids  and  alkalis  are  used.  Rambousek^"  cites 
cases  of  aniline  poisoning,  where  aniline  was  used  for  the  extraction  of  rubber. 
The  grinding  operation  involves  exposure  to  dust  of  a  mixed  character,  often 
containing  dangerous  amounts  of  lead.  Some  of  the  processes  involve 
exposure  to  a  very  steamy  atmosphere  and  wet  sloppy  work.  During  the 
grinding  process,  which  is  done  between  steel  rollers,  the  material  becomes 
heated  and  emits  bluish  and  very  irritating  vapors,   probably  antimony. 

Dr.  Crzellitzer,  cited  by  Neisser,^^  reports  a  case  of  retro-bulbar  neuritis 
in  a  man  engaged  in  grinding  refuse  and  fragments  of  hard  rubber.  On 
the  second  day  of  his  work  the  patient  developed  symptoms  of  headache, 
nausea,  dizziness  and  inflammation  of  the  eyes.  Dr.  Crzellitzer  leaves  the 
question  open,  whether  during  the  grinding  process  sufficient  heat  was 
developed  to  disengage  carbon  bisulphide,  or  whether  we  have  to  deal  with 
other  low  ebullition  compounds,  as  the  cause  of  these  symptoms. 

12.  Rubber  Substitutes. — Substitutes  for  rubber  have  been  made  by 
boiling  a  mixture  of  vegetable  oils,  sulphur,  and  resin,  with  chloride  of  sulphur, 
during  which  process  sulphureted  hydrogen  is  evolved  and  may  be  inhaled. 

Preventive  Measures. — In  view  of  the  far  reaching  and  evil  consequences 
of  bisulphide  of  carbon,  especially  in  the  rubber  industry,  its  use  should  be 
prohibited.  Until  this  is  accomplished,  the  curing  vats  should  be  low  placed 
since  the  vapors  are  heavy,  and  local  confining  apparatus  and  copious  down- 
ward exhaust  ventilation  for  the  removal  of  all  toxic  vapors  should  be  pro- 
vided. The  practice  of  dipping  with  unprotected  hands  should  be  stopped. 
Special  curing  and  drying  chambers  with  exhaust  ventilation  should  be  pro- 
vided and  aU  vessels  containing  poisonous  agents  should  be  kept  covered. 
Medical  inspection  and  suitable  work  suits  and  facilities  for  bathing  should 
be  provided,  and  all  dangerous  processes  should  be  limited  to  23'^-hour 
shifts,  with  alternation  of  work. 

REFERENCES 

^  Report  Mass.  State  Board  of  Health  Inspectors,  1910,  page  93. 

2  Hayhurst,  E.  R. — Industrial  Health  Hazards  and  Occupational  Diseases  in  Ohio,  Febru- 
ary, 1915. 
'  Roth.- — Gewerbehygiene,  1907. 

*  Oliver. — Dangerous  Trades,  London,  1902,  page  474. 

*  Rambousek. — Industrial  Poisoning,  London,  1913,  page  63. 
®  Laudenheimer. — Die  Schwefelkohlenstofif  Vergiftung,  1899. 

^  Koelsch. — Krankheit  und  Soziale  Lage,  Miinchen,  191 2,  page  186. 

*  Rambousek. — Industrial  Poisoning,  London,  1913,  page  69. 

^  Von  Harmsen. — Vierteljrschft.  f.  Gerichtl.  Med.,  Bd.  XXX,  149,  IQOS 
^^  Rambousek. — Industrial  Poisoning,  London,  1913,  page  69. 
"  Neisser. — Internal.  Ubersicht  uber  Gewerbehygiene,  Berlin,  1907. 


SECTION  IV 
PROCESSES  INVOLVING  EXPOSURE  TO  LEAD  POISONING 

BY  GEORGE  M.  KOBER.  M.  D.,  Washington.  D.  C. 

Lead  Smelting.  Manufacture  of  White  Lead.  Lead  Pipe  and  Plumbers'  Supplies. 
Plumbers,  Gas  and  Steam  Fitters.  Manufacture  of  Shot.  Painters.  Sand-papering 
of  Lead-painted  Surfaces.  Preventive  Measures.  (See  also  Section  V,  Division  I, 
Part  I,  Lead  Poisoning  in  U.  S.  and  III  on  India-rubber  Industry,  and  Division  II, 
Chap.  IV,  on  The  Printing  and  Publishing  Industry.) 

WORKERS  IN  LEAD  AND  ITS  COMPOUNDS 

All  occupations  involving  the  handling  of  lead  and  its  compounds  and  in 
which  lead  fumes  or  particles  of  lead  dust  may  be  inhaled,  swallowed,  or 
absorbed  must  be  regarded  as  dangerous  to  health.  Layet  has  enumerated 
no  trades  in  which  lead  poisoning  is  liable  to  occur,  but  there  are  doubtless 
many  other  occupations  in  which  lead  intoxication  may  take  place.  Neisser,^ 
for  example,  reports  a  fatal  case  in  a  man  who  spent  most  of  his  time  in  fish- 
ing and  contracted  lead  poisoning  by  the  habit  of  placing  the  lead  sinker  of 
the  fish  line  in  his  mouth;  another  fatal  case  occurred  in  a  saddler,  who  did  not 
handle  lead  in  any  other  way  except  that  he  used  occasionally  a  small  block 
of  lead  in  pounding  leather. 

Great  Britain  has  the  most  complete  statistics  on  the.  subject  of  lead 
poisoning,  notification  of  which  was  made  compulsory  in  1895.  Dr.  Legge^ 
has  tabulated  6762  cases  with  245  deaths,  which  occurred  in  different  in- 
dustries of  that  country  between  1900  and  1909,  both  inclusive.  I  have  ar- 
ranged his  table  according  to  frequency  as  follows:  Of  the  6762  cases,  1295 
were  reported  in  the  white  lead  industry,  1065  in  the  pottery  industry,  697 
in  coach  building,  422  in  the  manufacture  of  paints  and  colors,  452  in  paints 
used  in  other  industries,  412  in  smelting  of  metals,  285  in  electric  accumulator 
works,  269  in  ship  building,  217  in  plumbing  and  soldering  when  carried  on 
in  factory  premises,  211  in  file  cutting,  200  in  printing,  138  in  tinning  and 
enameling,  109  in  the  manufacture  of  sheet  lead  and  piping,  108  in  red  lead 
works,  75  in  l)rass  works,  52  in  enameling  iron  plates,  48  in  glass  cutting  and 
polishing,  48  in  litho-transfers  and  659  in  other  industries.  These  figures  do 
not  include  cases  among  house  painters  and  house  plumbers. 

Dr.  E.  R.  Hayhurst-'  reports  from  the  State  of  Ohio  between  July,  1913, 
and  November  30,  1914,  514  positive  and  138  tentative  cases  of  lead  poison- 
ing in  48  industries,  chiefly  in  the  manufacture  of  electric  apparatus,  storage 

512 


EXPOSURE    TO    OCCUPATIONAL   INTOXICATIONS  513 

batteries,  Babbitting  metals,  solder,  painting  automobiles  and  carriages,  and 
in  the  pottery  and  rubber  industry. 

Wachter,*  based  upon  a  study  of  1383  cases  of  lead  poisoning  in  Prussia, 
rates  the  risks  as  follows:  white  lead  workers,  7,^  per  cent.;  red  lead  workers, 
32  per  cent.;  shot  and  pipe  workers,  20  per  cent.;  painters,  7-10  per  cent.;  lead 
and  zinc  smelters,  8-9  per  cent.;  printers,  0.5  per  cent. 

Mining  of  lead  ore  involves  the  general  hazards  incident  to  metalliferous 
mines.  The  danger  from  lead  in  this  operation  is  generally  regarded  as  slight, 
unless  the  ore  contains  lead  in  the  form  of  carbonate  or  sulphide.  It  is  not 
improbable,  however,  that  the  subtle  forms  of  lead  poisoning  may  occur 
in  all  lead-ore  mining  from  the  ingestion  of  lead  dust. 

Lead  Smelting. — ^Lead  is  mostly  extracted  from  galena,  which  is  a  native 
lead  sulphide,  by  diflferent  processes,  known  as  the  roast  and  reaction  proc- 
ess, the  precipitation  process  and  the  roast  and  reduction  process.  The 
latter  is  most  commonly  employed.  Lead  usually  contains  also  other  metals, 
such  as  silver,  copper,  arsenic,  antimony,  iron,  zinc,  bismuth  and  tin.  For  the 
recovery  of  silver  the  lead  is  melted  and  oxidized  in  a  cupola  furnace,  during 
which  process  the  lead  is  converted  into  a  red  oxide,  litharge,  and  the  metallic 
silver  remains  behind. 

The  English  statistics  of  412  cases  of  lead  poisoning  in  smelting  of  metals 
include  253  cases  in  persons  engaged  in  the  smelting  of  lead  ores  and  in  de- 
silvering  lead,  99  in  the  manufacture  of  zinc  and  60  cases  in  smelting  other 
lead-containing  metals,  such  as  iron  or  copper  ore. 

The  men  who  charge  and  attend  to  the  furnaces,  the  flue  cleaners,  and 
those  employed  at  the  lead  and  slag  runs,  and  in  the  crushing  and  packing 
of  litharge,  are  most  exposed  to  lead  fumes  and  dust. 

The  operations  at  the  refining  furnaces  and  the  crushing  and  mixing 
and  transport  of  the  ore  are  less  dangerous. 

Of  999  employees  in  Prussian  lead  smelters^  in  1905,  177  suffered  from 
lead  colic  or  lead  palsy,  involving  3056  days  loss  of  work.  In  recent  years 
conditions  are  more  favorable.  In  1909  among  550  lead  smelters  near  Hildes- 
heim,  only  four  cases  of  lead  poisoning  were  reported  and  at  Potsdam  only 
five  among  660  workers.^ 

Miiller^  found  from  0.0029  to  0.00569  gram  of  lead  per  cubic  meter  in  the 
air  of  smelting  works,  and  the  water  in  which  the  hands  of  Htharge  grinders 
and  sifters  were  washed  was  found  to  contain  1.27  grams  of  lead  per  liter. 

White  Lead.— The  manufacture  of  white  lead  has  been  described  by  Dr. 
Ahce  Hamilton  on  page  106,  and  it  may  be  well  to  emphasize  the  fact  that 
the  men  who  empty  the  stacks  or  chambers,  and  those  who  are  engaged  in 
washing,  crushing,  grinding,  sifting  and  packing  of  dry  white  lead  are  espe- 
cially liable  to  plumbism.  In  Massachusetts*  we  are  informed  that  the  men 
who  empty  the  stacks  do  not  remain  long  at  work,  partly  because  of  their 
roving  disposition  and  the  disagreeable  character  of  the  work;  others  acquire 
lead  poisoning  and  are  obliged  to  quit,  and  even  those  of  good  intentions 
23 


514        ETIOLOGY   AND   PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

rarely  work  more  than  a  month.  According  to  Prof.  Roth,^  quite  a  number 
of  German  proprietors  of  white  lead  works  purposely  employ  men  of  roving 
disposition  or  make  frequent  changes,  quite  unmindful  of  the  fact  that  this 
very  class,  because  of  ignorance  and  neglect,  are  much  more  liable  to  contract 
lead  poisoning.  The  factory  inspectors  of  Great  Britain  long  ago  pointed 
out  the  danger  of  employing  casual  labor.  Dr.  Legge  reports  that  of  1463 
persons  employed  in  white  lead  works,  the  incidence  of  lead  poisoning  was  6 
per  cent,  among  the  regular  employees,  against  39  per  cent,  in  the  casual 
workers. 

Preventive  Measures. — Sanitarians  have  urged  for  years  the  substitu- 
tion of  less  harmful  substances  for  lead,  such  as  zinc  oxide  and  lithopone  for 
lead  paints,  leadless  glaze  in  potteries  for  lead  glaze,  tin  blocks  for  lead  beds  in 
file  cutting,  etc.  Excellent  preventive  measures  have  been  promulgated  and 
as  a  result  of  factory  sanitation,  official  regulations,  and  educational  methods 
a  gratifying  reduction  in  the  morbidity  and  mortality  from  plumbism  has 
taken  place.  For  example,  in  Great  Britain,  where  compulsory  notification 
exists,  the  number  of  cases  of  lead  poisoning  has  been  reduced  from  1278  in 
1898  to  505  in  1910.  The  percentage  of  severe  cases  in  men  was  23.9  against 
13.9  in  females,  possibly  due  to  the  fact  that  females  have  cleaner  habits  and 
also  stop  work  more  promptly  upon  the  appearance  of  the  first  symptoms. 

The  general  principles  embodied  in  official  regulations  should  provide 
for  (i)  the  removal  of  the  toxic  fumes  by  forced  ventilation;  (2)  reduction 
of  dust  production  by  the  wet  processes  and  automatic  machinery,  and  its 
removal  by  exhaust  ventilation.  (3)  Respirators  should  be  worn  and  the 
hours  of  labor  for  those  engaged  in  the  oxidation  chambers  and  other  dusty 
processes  should  be  shortened,  with  alternation  of  work.  (4)  Lockers 
should  be  provided  so  as  to  protect  the  street  clothing  worn  by  the  em- 
ployees. (5)  Washing  and  bathing  facilities  should  be  provided.  (6) 
Special  lunch  rooms  are  necessary.  (7)  Semi-monthly  medical  inspection 
of  employees,  suspension  of  work  in  case  of  sickness,  and  re-examination 
before  returning  to  work  should  be  enforced.  (8)  Alcohol  and  tobacco 
should  be  forbidden  during  the  working  hours. 

In  the  way  of  individual  hygiene,  personal  cleanliness,  temperate  habits, 
good  food  and  fresh  air  are  important.  The  work  should  be  done  in  over- 
alls, frequently  changed  and  washed.  The  head  should  be  covered  with 
suitable  caps;  short  hair  and  no  beard  offer  distinct  advantages.  Before 
meals  the  exposed  parts  of  the  body  should  be  "dry  dusted,"  the  hands, 
face  and  nostrils  thoroughly  washed  with  soap  and  warm  water,  and  the 
mouth  and  throat  rinsed  with  a  solution  of  tartrate  of  ammonia. 

All  health  rules  should  be  conspicuously  posted  and  the  attending 
physicians  should  educate  the  employees  so  that  they  may  guard  against 
the  dangers,  remembering  always  Sir  Thomas  Oliver's  view  that  lead  poi- 
soning may  be  easily  caused  and  almost  as  easily  prevented,  especially  by 
personal  cleanliness.     The  so-called  sanitary  drinks,  made  of  epsom  salt, 


EXPOSURE  TO  OCCUPATIONAL  INTOXICATIONS  515 

lemon  juice,  etc.,  are  of  little  avail;  there  is  at  present  no  real  antidote  to 
this  subtle  poison. 

Lead  Pipe  and  Plumbers'  Supplies. — The  men  engaged  in  the  manu- 
facture of  lead  pipe  and  plumbers'  supplies  are  exposed  to  lead  poisoning 
not  only  from  the  fumes,  but  also  from  dust  in  handling  sheet  lead. 

The  manufacture  of  solder  involves  similar  risks.  Common  solder  is  a 
mixture  of  equal  parts  of  lead  and  tin.  Hard  or  fine  solder  is  composed  of 
two  parts  of  tin  and  one  of  lead,  and  coarse  or  soft  solder  contains  two  parts 
of  lead  and  one  of  tin. 

The  Massachusetts  Report^"  speaks  approvingly  of  the  efforts  of  the 
manufacturers  of  plumbers'  supphes  to  carry  off  the  dust  and  fumes  by 
hoods  and  exhaust  ventilation,  that  all  the  employees  took  the  necessary 
precaution  and  in  no  instance  was  it  possible  to  trace  a  case  of  lead  poison- 
ing to  faulty  methods.  In  an  establishment  for  the  manufacture  of  solder, 
although  rats,  cats  and  dogs  appear  to  succumb  to  lead  poisoning,  only  one 
case  of  plumbism  occurred  among  the  employees  in  35  years. 

Plumbers,  Gas  and  Steam  Fitters. — These  occupations  are  often  carried 
on  under  unfavorable  environments,  especially  in  new  construction,  which 
involves  ditch  work  and  exposure  to  dampness  in  cellars  and  basements. 
Exposure  to  lead  is  unavoidable  in  handling,  cutting,  and  filing  of  lead 
pipes,  bends,  traps,  etc.,  and  also  in  the  employment  of  white  or  red  lead  for 
making  joint  connections.  The  use  of  solder  involves  exposure  to  lead  and 
acid  fumes  and  the  products  of  combustion  of  either  an  open  charcoal  fire 
or  a  gasoline  torch.  Cases  of  arseniureted  hydrogen  poisoning  have  been 
reported  in  plumbers,  and  the  hydrogen  flame  constitutes  a  distinct  menace. 
Unwashed  hands  doubtless  play  a  frequent  role  in  the  ingestion  of  lead. 
Sternberg^^  has  reported  wholesale  cases  of  plumbism  in  Vienna  among  this 
class  of  workers.  The  accident  risk  in  new  construction  work  is  not  in- 
considerable; the  morbidity  hazard  among  the  Leipsic  plumbers  and  gas 
fitters  amounts  to  836  days  per  100  workers  per  annum,  with  a  mortality 
hazard  of  0.60  per  cent.  Hoffman's^^  statistics,  based  upon  1133  deaths 
among  plumbers,  show  that  32.9  per  cent,  of  the  mortality  from  all  causes 
was  due  to  tuberculosis,  followed  by  accidents  with  11. 7  per  cent.;  diseases 
of  the  urinary  organs,  ii.i  per  cent.;  pneumonia,  7.7  per  cent.;  heart  disease, 
5.2  per  cent. 

Manufacture  of  Shot. — In  the  manufacture  of  shot,  metallic  lead  is 
fused  with  arsenious  acid  or  more  frequently  with  metallic  arsenic  in  suitable 
proportions.  Arsenic  is  added  to  harden  the  shot.  When  the  mixture  is 
ready  it  is  poured  through  sieves  of  different  sizes  at  the  top  of  a  tower 
filled  with  water  at  the  base,  which  hardens  the  lead  drops.  The  shot  is 
subsequently  polished  by  means  of  graphite  in  a  revolving  drum.  The 
fusion  process  involves  exposure  to  both  lead  and  arsenic  unless  guarded 
against  by  suitable  crucibles. 

Painters. — This  occupation  covers  a  large  number  of   specialties,  and 


5l6         ETIOLOGY    AND    PROPHYLAXIS    OF    OCCUPATIONAL    DISEASES 

some  industrial  statistics  include  even  glazers,  white  washers  and  paperhangers 
under  the  general  head  of  painters,  decorators  and  paperhangers. 

The  general  classification  suggested  by  Dr.  Hamiltoni^  includes  house, 
sign,  and  ship  painters;  coach  painters,  inclusive  of  wagons  and  carriages, 
automobiles,  railway  and  street  railway  coaches,  bridge,  tank,  and  structural 
iron  painters;  painters  of  agricultural  implements,  furniture,  picture  frames 
and  mouldings.  It  is  obvious  that  the  ocu^iational  risks  vary  considerably 
in  the  different  departments,  and  depend  to  a  great  extent  upon  the  materials 
employed,  the  character  of  the  work,  the  conditions  under  which  the  work  is 
performed  and  the  precautions  taken  by  the  workers. 

Hoffman's  Industrial  Insurance  Statistics^^  show  that  of  2783  deaths 
among  painters  23.8  per  cent,  were  caused  by  tuberculosis,  and  9.9  per  cent, 
from  other  respiratory  diseases,  making  a  combined  rate  of  33.7  per  cent, 
from  diseases  of  the  respiratory  organs;  the  rate  from  lead  poisoning  was  1.5 
per  cent.;  from  nervous  diseases  10.7  per  cent.;  from  heart,  kidney  and  liver 
diseases  ^5.9  per  cent.  The  German  figures,  cited  by  Fleck, ^^  are  41.6 
per  cent.,  1.3  per  cent.,  7.8  per  cent,  and  20.8  per  cent,  respectively.  The 
Leipsic  Sick  Benefit  records  show  1017  days  of  sickness  a  year  per  100  mem- 
bers and  a  mortality  hazard  of  0.72  per  cent. 

The  composition  of  paint  may  be  very  simple  or  quite  complex.  Among 
the  poisonous  pigments  should  be  mentioned  those  containing  arsenic,  lead 
and  mercurial  compounds,  and  among  the  liquid  vehicles,  driers  and  var- 
nishes, which  may  act  as  industrial  poisons,  are  turpentine,  benzine,  benzol, 
creasote,  wood  alcohol,  asphaltum,  amyl  acetate,  banana  oil  (a  mixture  of 
amyl  acetate,  acetone  and  benzine)  and  carbon  disulphide. 

All  quick-drying  flat-finish  paints  or  varnishes  are  generally  made  of 
leadless  pigments,  but  usually  contain  some  of  the  petroleum  products,  which 
may  be  a  source  of  benzine  poisoning,  as  the  work  has  to  be  done  in  closed 
rooms  because  open  windows  and  drafts  cause  the  paint  to  dry  too  rapidly 
and  render  the  coat  streaky. 

The  danger  from  arsenical  and  mercurial  pigments  has  been  pointed  out  no 
pages  3,  126,  486.  Lead  poisoning  among  painters  has  long  since  character- 
ized this  occupation  as  a  dangerous  trade.  Koelsch^^  in  a  careful  study  of 
5000  painters  in  Munich  found  that  only  8  per  cent,  were  over  50  years  of  age; 
the  majority  were  between  16  and  40  years  of  age.  Of  this  number  13.83  per 
cent,  had  experienced  symptoms  of  lead  poisoning;  about  one-third  had 
suffered  from  more  than  one  acute  attack.  Colic  occurred  in  about  85  per 
cent,  of  the  cases;  lead  palsy  in  3.5  per  cent.;  joint  affections  in  2.7  per  cent.; 
sciatica,  visual  disturbances,  renal  involvement  and  gout  in  about  2  per  cent, 
of  the  cases.  Cases  of  lead  poisoning  involving  the  brain  were  not  encoun- 
tered, since  the  physical  examination  was  limited  to  actual  workers;  the 
hospital  records  of  Munich  show,  however,  a  proportion  of  5.5  per  cent. 
About  29  per  cent,  of  all  the  workers  examined  showed  objective  or  subjective 
symptoms  of  lead  poisoning;  11.8  per  cent,  revealed  the  characteristic  gum 


EXPOSURE  TO  OCCUPATIONAL  INTOXICATIONS  517 

lines;  6.5  per  cent,  were  anaemic;  digestive  disorders,  headache,  tremor,  dizzi- 
ness, circulatory  and  kidney  disorders  and  rheumatic  affections  were  not 
infrequent. 

Koelsch's  general  percentage  corresponds  very  closely  with  the  results 
obtained  by  the  Illinois  Commission  on  Occupational  Diseases  for  191 1,  which 
show  that  of  578  cases  of  lead  poisoning,  27  per  cent,  were  painters.  The 
statistics  of  Pratt  and  Andrewi,  cited  by  Dr.  Hamilton, ''  indicate  a  higher 
percentage.  The  average  age  of  1388  painters,  decorators  and  paperhangers 
in  Chicago  in  191 1  was  41  years  and  3  months.  It  is  of  interest  to  note 
that  the  painters  examined  by  Dr.  Hay  hurst  were  encouraged  to  state  what 
they  considered  the  most  unhealthful  feature  of  their  work  and  99  out  of 
100  mentioned  the  lead-paint  dust  from  sand-papering,  70  complained  of 
benzine,  64  of  turpentine  when  used  in  close  quarters,  and  nearly  all  stated 
that  the  fumes  of  benzine  and  turpentine  in  hard  oiling  made  them  sick 
temporarily.  Three  of  the  men  had  been  victims  of  wood  alcohol  blindness, 
contracted  while  working  in  brewery  vats. 

Hayhurst'^  in  his  Ohio  Survey  reports  154  cases  of  lead  poisoning,  three 
from  benzine  and  naphtha,  two  from  turpentine  and  one  each  from  varnish 
and  wood  alcohol. 

It  has  been  shown  by  Gardner^ ^  that  drying  paints  emit  no  metallic 
vapors,  but  they  may  evolve  benzol,  formic  acid,  aldehyde  substances, 
carbon  dioxide  and  carbon  monoxide,  and  while  all  are  more  or  less  harmful, 
he  very  properly  maintains  that  carbon  monoxide  may  be  a  fruitful  cause  of 
anaemia  among  painters.  These  conclusions  naturally  suggest  the  need  of 
copious  ventilation. 

Causes  of  Lead  Poisoning  among  Painters 

1.  Mixing  Dry  Lead  Pigments  with  Oil  or  Paints. — This  source  of  danger 
is  not  pronounced,  as  most  of  the  paints  are  manufactured  in  special  establish- 
ments and  very  few  painters  have  occasion  to  use  dry  pigments,  except 
those  employed  in  structural  iron  painting  who  use  red  lead.  Of  100  cases 
of  lead  poisoning  cited  by  Dr.  Hamilton^-  only  two  had  used  dry  white  or  red 
lead.  Unless  the  mixing  is  done  carefully,  or  in  inclosed  machinery,  there 
is  danger  from  dust  inhalation. 

2.  Sandpapering  of  Lead  Painted  Surfaces. — This  is  universally  acknowl- 
edged to  be  the  most  important  cause  of  lead  poisoning  among  painters, 
as  the  evolution  of  dust  by  dry  sandpapering  or  rubbing  with  pumice-stone, 
naturally  favors  inhalation  or  ingestion  of  dust  containing  lead  or  other 
toxic  agents.  It  is  believed  also  that  the  sharp,  angular  character  of  sand 
or  pumice-stone  dust  renders  the  mucous  membrane  vulnerable  and  hence 
more  susceptible  to  the  absorption  of  toxic  dust. 

The  removal  of  old  paint  by  means  of  benzine,  wood  alcohol,  compressed 
air,  chipping,  or  scraping  is  equally  dangerous  work,  especially  when  this 
has  to  be  done  in  confined  spaces,  notably  between  the  outer  and  inner  shell 


5l8        ETIOLOGY   AND    PROPHYL.^XIS    OF    OCCUPATIONAL  DISEASES 

of  Steel  ships.  Burning  off  the  old  paint  by  means  of  a  small  gasoline  torch 
is  a  safer  method,  as  there  is  little  or  no  danger  from  lead  fumes,  unless  the 
workman  permits  the  flame  to  play  long  enough  on  the  surface  to  volatilize 
the  lead  and  produce  a  decided  smoke,  in  which  case  particles  of  lead  may, 
in  the  opinion  of  Prof.  Stieglitz,  be  carried  off  mechanically  with  the  smoke. 
The  inhalation  of  lead  dust  from  dirty  drop  cloths  and  overalls  is  doubtless 
a  frequent  cause  of  plumbism  among  house  painters  and  decorators.  And 
for  obvious  reasons  the  men  should  also  be  careful  not  to  expose  their  street 
clothing  to  lead-containing  dust. 

The  ingestion  of  lead  through  unwashed  hands,  etc.,  while  eating,  drinking, 
smoking,  or  handling  tobacco  and  pipes,  is  naturally  a  frequent  cause  of 
plumbism.  While  every  painter  knows  that  "hot  water  and  soap  and  time 
enough  to  use  them"  are  important  protective  measures,  the  fact  is  that 
these  facilities,  except  in  shop  work,  are  not  always  available.  In  new  con- 
struction work  and  vacant  houses  the  water  may  not  be  turned  on,  and  the 
workman  is  obliged  therefore  to  clean  his  hands  with  benzine,  turpentine,  etc., 
provided  for  cleaning  the  paint  brushes,  and  those  who  fear  that  these  agents 
drive  the  lead  into  the  pores  of  the  skin,  simply  resort  to  a  piece  of  rag,  cotton 
waste,  or  paper  for  the  removal  of  gross  particles  of  lead. 

Among  the  contributory  factors  to  lead  poisoning  should  be  mentioned 
chronic  alcoholism.  My  personal  observations  lead  me  to  conclude  that  the 
alcohol  habit  is  quite  prevalent  among  painters,  and  old  topers  do  not  hesi- 
tate to  tipple  alcohol  from  shellac  and  even  denatured  alcohol.  Pieraccini 
has  pointed  out  that  lead  in  the  system  creates  a  desire  for  alcohol,  and  that 
the  combined  effects  quickly  damage  the  kidneys  and  arteries.  The  life 
Insurance  statistics,  on  the  other  hand,  indicate  that  only  1.4  per  cent,  of  the 
2783  deaths  among  painters  were  caused  by  alcoholism,  as  against  1.9  per 
cent,  for  plumbers  and  masons  and  an  average  of  1.5  per  cent,  for  103,434 
occupied  males.     The  German  and  French  statistics  are  not  so  favorable. 

The  liability  to  accidents,  such  as  falls  from  ladders  and  scaffolds,  is  not 
inconsiderable  and  house  painters  are  likewise  exposed  to  electric  shocks  from 
overhead  wires.  Exposure  to  the  elements  doubtless  plays  an  important  role 
in  the  causation  of  catarrhal  and  rheumatic  affections  and  diseases  of  the 
respiratory  organs.  Pneumonia,  according  to  Hirt,  is  more  common  among 
house  painters  than  in  decorators  and  varnishers.  Diabetes  is  reported  by 
Rosenfeld  as  not  uncommon.  Affections  of  the  eyes,  from  exposure  to  dust, 
toxic  fumes,  etc.,  are  likewise  quite  frequent,  and  dental  and  gastric  diseases 
are  equally  common.  See  also  diseases  of  the  circulatory  organs,  arterio- 
sclerosis and  diseases  of  the  kidneys.  Flat-foot,  knock-knee,  and  varicose 
veins  as  a  result  of  prolonged  standing  are  not  uncommon,  and  housemaid's 
knee  has  been  noted  among  men,  who  make  a  specialty  of  painting  or  polish- 
ing floors.  Callosities  of  the  palm  of  the  hands,  and  inflammatory  affections 
of  the  skin  of  the  hands  and  arms  caused  by  turpentine  and  petroleum  products 
are  not  infrequent. 


EXPOSURE  TO  OCCUPATIONAL  INTOXICATIONS  519 

Preventive  Measures. — Dr.  Hamilton  has  pointed  out  on  page  116  the 
salient  features  in  the  prevention  of  lead  poisoning  among  painters.  Pro- 
fessor Sommerfeld  regards  dry  sandpapering  as  the  most  fruitful  cause  of  lead 
poisoning  and  hence  no  effort  should  be  spared  to  substitute  moist  processes 
and  to  resort  to  all  the  precautions  referred  to  on  page  514. 

The  French  Government  has  adopted  radical  measures  for  the  suppression 
of  white  lead  paint,  to  take  effect  January  i,  191 5.  According  to  the  Monthly 
Review  of  the  U.  S.  Bureau  of  Labor  Statistics  for  November,  1915,  a  com- 
mittee appointed  by  the  Home  Department  of  Great  Britain  recommends 
the  enactment  of  a  law  prohibiting  the  importation,  sale,  or  use  of  any  paint 
material  containing  more  than  5  per  cent,  of  its  dry  weight  of  a  soluble  lead 
compound.  Germany  has  forbidden  the  mixing  of  white  lead  by  hand, 
and  insists  that  the  rubbing  of  fresh  or  old  paint  with  sandpaper  or  pumice 
may  be  done  only  after  previous  dampening.  Austria  has  a  similar  law  and 
also  forbids  the  use  of  white  lead  for  inside  work  except  in  certain  cases. 
The  German  law  also  requires  that  the  contractor  for  house  painting  shall 
provide  caps  and  suitable  overalls,  kept  in  order  and  washed,  and  temporary 
working  sheds,  where  the  men  may  keep  their  street  clothing,  keep  and  eat 
their  lunches,  supplied  with  warm  water,  soap,  wash-basins,  nailbrushes, 
and  towels.  The  employer  must  suspend  from  work  any  painter  known 
to  him  to  be  suffering  from  lead  poisoning.  The  law  regulating  painting 
in  factories  also  forbids  the  use  of  alcohol  and  tobacco,  and  provides  for 
medical  inspection  of  employees  at  least  every  6  months.  A  few  of  the 
states  have  enacted  laws  for  the  protection  of  workers  in  lead,  some  of  the 
laws  cover  also  painters  when  employed  in  factories  or  workshops. 

The  Brotherhood  of  Chicago  painters  and  paperhangers  during  a  strike 
in  April,  1913,  formulated  the  following  reasonable  demand:  "no  workman 
or  apprentice  shall  be  required  to  use  any  poisonous  substance  or'material 
injurious  to  health,  such  as  wood  alcohol,  varnish  remover,  oxalic  acid,  or 
the  sanding  of  lead,  etc.,  unless  they  are  protected  with  respirators,  gloves, 
etc.,  same  to  be  furnished  by  the  employer;  nor  shall  they  be  required  to 
use  any  dirty  or  insanitary  waste,  rags  or  drop  cloths.  There  shall  be  an 
allowance  of  5  minutes  for  wash  time  in  each  4  hour's  work,  and  where  lead 
or  other  poisonous  material  is  used,  the  employer  shall  furnish  hot  water,  soap 
and  towels  to  the  workmen.  The  officers  and  members  of  the  organization 
shall  enforce  this  clause." 

Robinson  and  Wilson^^  inspected  five  factories  engaged  in  the  manufacture 
of  white  lead  and  paints,  and  examined  226  workers,  none  of  whom  were 
found  to  be  tuberculous  and  but  five  whose  physical  condition  was  below  par. 
This  favorable  showing  is  attributed  to  the  strict  medical  supervision  over 
the  workers,  primarily  intended  for  the  prevention  of  lead  poisoning.  In 
operations  producing  dust  this  hazard  was  minimized  by  the  use  of  blowers. 

Only  one  of  the  establishments  had  any  cuspidors  but  in  insufficient 
numbers.     Spitting  on  the  floor  was  noted  in  all.     Toilet  and  washing  facili- 


520        ETIOLOGY    AND    PROPHYL.-VXIS    OF    OCCUPATIONAL    DISEASES 

ties  were  good  in  three  and  only  fair  in  three  estabUshments.  In  the  white 
lead  factory  the  floors  were  mopped  every  morning,  while  two  of  the  other 
places  were  sprinkled  and  swept  in  the  morning  and  two  others  were  swept 
after  working  hours. 

REFERENCES 

^  Neisser. — Internat.  tjbersicht  liber  Gewerbehygiene,  1907. 

^Legge,  T.  M. — Actes  du  II  Congress  Maladies  Professionelles,  Brussells,  1910. 

'  Industrial  Health  Hazards  and  Occupational  Diseases  in  Ohio,  February,  1915. 

*  Wachter,  Karl. — Die  Gewerbliche  Bleivergiftung  im  Deutschen,  Reiche,  1908. 
'  Roth  Gewerbehygiene,  1907. 

*  Rambousek. — Industrial  Poisoning,  London,  1913. 

^  Miiller. — Die  Bekampfung  der  Bleigefahr  in  der  Industrie,  Jena,  1908. 

*  Report  of  the  State  Board  of  Health  of  Mass.  upon  Sanitar\^  Conditions  of  Factories 

and  Workshops,  1907. 
'  Roth. — Gewerbehygiene,  1907. 
^'^  Report  of   the   State   Board  of   Health   of   Mass.   upon    the    Sanitary    Condition   of 

Factories,  Workshops,  etc.,  1907. 
*^  Sternberg. — Medical  Reform,  1906.  No.  50. 

^''Hamilton,  Alice.— Bulletin  120,  U.  S.  Dept.  of  Labor,  May,  1913. 
^^  The  Prudential  Insurance  Company   of  America,   191 2. 
"  Fleck,  Albert. — Weyl's  Handbuch  d.  Arbeiterkrankheiten,  Jena,  1908. 
^*  Koelsch,  cited  by  Brezina.     Oestr.  Sanitatswesen,  19 13. 
**  Jour.  Ind.  and  Eng.  Chemistry,  Vol.  VI,  page  91,  Feb.,  1914. 
'^  Robinson,  D.  C,  and  Wilson,  J.  G. — ^U.  S.  Public  Health  Bulletin,  No.  73,  March,  1916. 


SECTION  V 
PROCESSES  INVOLVING  EXPOSURE  TO  MERCURIAL  POISONING 

BY  LUDWIG  TELEKY.  M.  D.,  Vienna,  Austria,  AND  GEORGE  M.  KOBER.   M.  D., 

Washington,  D.  C. 

Mining. t  Smelting.*  Manufacture  of  Physical  Apparatus.*  Extraction  of  Gold  and 
Silver.*  Fire  Gilding.*  Manufacture  of  Electrodes  and  Storage  Batteries.* 
Mercurial  Chemical  Compounds.!  Mirror  Plating. f  Hatters'  Fur  Cutting  and  the 
Felt  Hat  Industry,  f     General  Preventive  Measures,  f 

WORKERS  IN  MERCURY  AND  ITS  SALTS 

Mining  of  the  Ore.f — Of  the  total  output  of  4300  metric  tons  in  1912, 
855  tons  v^^ere  produced  in  the  U.  S.  Mercury  is  chiefly  obtained  from  the 
sulphide  of  mercury  ore,  commonly  known  as  cinnabar  (HgS).  Pure 
cinnabar  contains  86.2  per  cent,  of  mercury,  the  ordinary  ore  contains 
generally  less  than  i  per  cent.,  exceptionally  2.5  per  cent,  as  in  Brewster 
County  Texas,  and  as  high  as  9  per  cent,  in  the  mines  of  Almaden  in  Spain. 
Since  cinnabar  is  insoluble  there  should  be  no  danger  from  this  source. 
Dr.  Pope  of  London  as  early  as  1665  referred  to  mercurial  tremor  of  the  hands 
among  the  miners  of  Italy.  The  eleventh  census  of  the  United  States,  page 
28,  reports  that  10.44  per  cent,  of  the  men  employed  in  the  New  Almaden 
mines  suffered  from  mercurialism.  Such  instances  are  doubtless  due  to  the 
fact  that  mercury  in  certain  mines  and  galleries  'has  been  known  to  collect 
in  small  and  large  drops,  which  under  the  influence  of  a  very  warm  and 
moist  atmosphere  is  volatilized  and  inhaled. 

According  to  Dr.  Teleky  the  mines  at  Monte  Amiata  are  quite  free 
from  such  a  risk,  while  those  of  Idria  and  especially  the  Spanish  mines 
present  this  danger.  In  all  such  cases  it  has  been  found  practicable  to 
reduce  the  danger  by  copious  ventilation,  and  by  a  change  of  crews  to  other 
locations,  so  that  the  men  may  not  work  over  4  hours  in  dangerous  places. 

Smelting.* — Mercury  is  usually  obtained  by  subjecting  cinnabar  (mer- 
curic sulphide)  to  a  roasting  process  in  furnaces.  By  this  procedure  the 
sulphur  combines  with  oxygen,  forming  sulphur  dioxide,  while  the  mercury 
which  distils  off,  is  collected  in  special  receptacles.  The  aim  of  the  tech- 
nologist on  the  one  hand  is  to  bring  about  a  comparatively  complete 
disintegration  of  the  ore  and  on  the  other  he  seeks  to  keep  the  escape  of 
mercurial  vapors  from  the  furnaces  down  to  a  minimum.  In  this  endeavor 
technology  and  hygiene  join  hands,  because  mercurial  vapors  are  a  source  of 

*By  Ludwig  Teleky,  Vienna,  Austria. 
fBy  George  M.  Kober,  Washington,  D.  C. 

521 


52  2        ETIOLOGY   AND   PROPHYLAXIS   OF   OCCUPATIONAL  DISEASES 

grave  danger  to  the  workmen.  Above  all  things  in  this  industry  it  is  nec- 
essary to  build  condensers  of  sufficient  spaciousness  so  as  to  make  the  con- 
densation of  mercury  as  complete  as  possible.  At  Idria,  in  Austria-Hungary, 
the  outlet  of  the  stack  is  158  meters  above  the  arch  of  the  smelter  and  the 
total  content  of  the  condensing  plant  is  7631  cubic  meters. 

If  a  condensing  plant  is  not  sufficiently  effective  there  occurs  on  the  one 
hand  a  colossal  loss  of  mercury,  and  on  the  other  there  is  danger  of  jeop- 
ardizing not  only  the  health  of  the  workmen  but  also  that  of  persons  living 
in  the  vicinity  of  the  smelter. 

In  Idria,  in  previous  years  it  was  apparently  a  common  thing  to  have 
stock  poisoned  as  a  result  of  grazing  on  lands  in  the  neighborhood  of  the 
smelter. 

Even  when  the  amount  of  mercury  escaping  from  a  stack  is  small  it 
must  be  regarded  as  dangerous  to  smelter  workers  when  the  outlet  of  the 
chimney  is  not  sufficiently  distant  from  the  smelter  or  if  it  is  badly  placed. 

The  greatest  source  of  danger,  however,  is  from  vapors  escaping  from 
the  furnaces  within  the  smelter.  Escape  of  vapors  can  be  prevented  only 
when  a  negative  pressure  exists  in  the  furnaces.  A  negative  pressure  is 
maintained  by  a  mechanically  driven  ventilator  (fan)  which  exerts  its 
activity  throughout  the  entire  furnance  system.  It  often  occurs  that  the 
wings  of  a  ventilator  become  corroded  by  the  acid  vapors  which  pass  through 
the  stack  and  consequently  it  is  important  at  all  times  to  hold  an  extra  fan 
in  reserve. 

In  shaft  furnaces,  employed  in  the  working  up  of  coarse  ore,  difficulty 
is  experienced  in  affecting  a  complete  seal  for  preventing  the  escape  of  mer- 
cury vapors.  Giglioli,  for  instance,  found  that  the  apparently  efficient 
seal  of  Spirek  also  allows  mercury  vapor  to  escape.  A  condition  similar  to 
the  one  prevailing  in  the  shaft  ovens  often  obtains  with  the  continuous 
automatic  reverberatory  furnaces  (Fortschauflerofen). 

In  the  most  modern  furnaces  (Czermak-Spirek  Schiittrostofen)  the  fine 
ore  which  is  worked  up  therein  serves  as  a  seal.  Even  with  this  device  one 
must  be  cautious.  In  working  with  this  type  of  oven  it  is  especially  nec- 
essary to  feed  only  ore  which  has  the  proper  degree  of  fineness,  and  to  have 
the  uppermost  layer  of  ore  of  a  proper  height.  It  is,  furthermore,  important 
to  have  a  pipe  with  an  especially  strong  suction  in  the  upper  layers  of  ore 
for  the  purpose  of  intensifying  an  existing  negative  pressure  in  the  furnace., 

The  greatest  advantage,  from  a  hygienic  standpoint,  obtained  by  employ- 
ing the  Czermak-Spirek  (Schiittrostofen)  furnace,  is  in  the  fact  that  the 
ore  under  treatment  falls  by  gravity  during  the  smelting  process  and  con- 
sequently does  not  require  further  handling  by  the  workmen. 

With  all  types  of  furnaces,  however,  great  care  must  be  exercised  when 
removing  the  spent  ore.  In  this  case  it  is  especially  necessary  to  see  that  the 
workman  who  opens  the  grate  bars  is  not  overcome  by  mercury  vapors  and 
dust.     This  can  be  prevented  by  placing  a  wall  of  sheet-iron  between  the  spent 


EXPOSURE  TO  OCCUPATIONAL  INTOXICATIONS         523 

ore  cart  and  the  spot  where  the  workman  usuaUy  stands,  and  by  instalHng 
suction  pipes  in  appropriate  localities.  The  carts,  when  filled  with  spent  ore, 
which  is  cooled,  should  be  conveyed  to  the  spent  ore  heap  automatically. 
(At  Idria  spent  ore  contains  0.00036  to  0.00148  per  cent,  of  Hg.) 

The  gases  which  are  produced  in  the  furnace  by  the  smelting  process  go 
over  into  condensers  of  large  dimensions.  In  the  condensers  a  soot  tech- 
nically called  "stupp"  collects  which  consists  of  a  mixture  of  finely  divided 
mercury,  unburned  particles  of  carbon,  undecomposed  hydrocarbons,  ore 
dust  and  ash.  As  only  a  comparatively  small  portion  of  metallic  mercury 
(5  to  10  per  cent.)  is  obtained  from  the  condensers,  it  becomes  necessary  to 
subject  the  soot  (stupp)  to  special  treatment  in  order  to  extract  the  mercury 
which  it  contains.  The  mercury  content  in  stupp  is  variable,  the  amount 
depending  upon  the  locality  from  which  it  is  obtained. 

The  removal  of  soot  from  the  condensers  must  be  regarded  as  an  occupa- 
tion which  is  quite  detrimental  to  the  health  of  those  engaged  in  it.  When 
practicable  plenty  of  water  should  be  played  during  the  operation.  Es- 
pecially dangerous  is  the  operation  in  cleansing  the  entire  canal  system.  At 
this  time  it  is  necessary  to  stop  all  smelting  operations,  and  once  each  year 
at  Idria  the  works  are  at  a  standstill  for  this  purpose.  To  prevent  disease 
as  much  as  possible  from  this  source  requires  the  wearing  of  special  clothing, 
the  employment  of  respiratory  apparatus  and  baths  at  the  end  of  each  work- 
ing period.  The  working  period  should  not  be  over  4  hours  for  each  shift. 
The  extraction  of  mercury  from  stupp  (soot)  is  done  with  specially  designed 
presses.  The  presses  should  be  provided  with  strong  suction  devices  for  the 
purpose  of  carrying  off  noxious  dusts  and  gases. 

Every  manipulation  associated  with  the  handling  of  stupp  should  be 
regarded  as  a  source  of  danger  to  health  because  poisoning  can  occur  from 
volatized  mercury  or  by  the  absorption  of  finely  divided  mercury  in  a  manner 
similar  to  the  poisoning  which  sometimes  occurs  when  blue  ointment  is 
rubbed  on  the  skin.  There  is  even  danger  of  poisoning,  through  volatiliza- 
tion and  absorption,  during  the  operation  of  weighing  and  filling  mercury 
into  cast-iron  flasks,  etc.  Accordingly  it  is  advisable  to  keep  the  flask  cov- 
ered and  to  avoid  spilling  the  metal,  and  to  prevent  mercury  from  coming 
into  contact  with  the  hands.  In  rooms  where  metallic  mercury  is  handled 
the  floors  should  be  smooth  and  tight  and  should  slope  in  the  direction  of  a 
vat  for  the  collection  of  mercury  droppings.  The  same  requirements  hold 
good  for  work  tables  on  which  mercury  is  handled. 

Eating  should  not  be  permitted  in  the  smelters  and  as  additional  general 
precautionary  measures  the  help  should  be  required  to  wash  the  hands  and 
to  take  a  bath  daily  before  leaving  the  smelter.  It  is  also  important  that  the 
help  wear  clothing  made  of  close-meshed  fabrics  for  the  purpose  of  preventing 
the  penetration  of  the  underwear  with  soot  and  mercurial  vapors.  Where 
this  precaution  is  not  taken  the  workmen  are  apt  to  carry  mercury  into  the 
home.     In  doing  this  the  workman  jeopardizes  not  only  his  own  health,  by 


524        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

being  continuously  in  an  environment  of  mercury,  but  also  that  of  the  other 
occupants  of  the  same  house.  At  Idria  cases  of  poisoning  are  often  noted 
among  members  of  a  mercury  worker's  family.  This  is  especially  true 
where  children  sleep  in  the  same  bed  with  a  father  who  is  engaged  in  a 
mercury  works. 

From  what  has  been  said  it  is  evident  that  the  untoward  effects  of 
mercury  can  be  minimized  if  effective  technical  and  hygienic  appliances  are 
installed  in  the  smelter.  It  is  also  obvious  that  a  complete  prevention  of 
disease  from  this  cause  is  impossible. 

Under  these  conditions  much  can  be  gained  by  making  frequent  changes 
among  the  help  and  no  person  should  be  allowed  to  work  over  4  weeks  at  a 
time  in  the  smelter.  Each  period  of  smelter  work  should  be  followed  by  a 
comparatively  longer  period  of  labor  at  a  less  dangerous  task,  as  mine  work, 
etc.  At  Idria  the  help  is  required  to  work  i  month  in  the  smelter  and  the 
following  2  to  3  months  in  the  mine. 

Although  the  technical  equipment  at  Abbadia  San  Salvador  is  not  less 
perfect  than  that  of  the  works  at  Idria,  the  incidence  of  mercury  poisoning 
is  much  greater.  At  Idria  among  1200  miners  I  found  nine  severe  cases  of 
mercury  poisoning.  Five  of  these  cases  had  received  pensions  for  several 
years,  and  the  remainder  were  still  engaged  in  active  work.  I  have  frequently 
observed  shght  cases  of  mercurialism  and  among  a  group  of  259  woikers 
there  were  only  19  who  gave  a  history  which  would  rule  out  mercury  poison- 
ing. The  death  rate  at  Idria  is  abnormally  high  and  many  die  from 
tuberculosis. 

Manufacture  of  Physical  Apparatus.* — The  utilization  of  mercury  for 
constructing  various  kinds  of  physical  apparatus  was  and  still  is  a  source  of 
mercury  poisoning. 

In  constructing  the  mercury  barometer  a  great  deal  of  mercury  is 
employed  and  it  often  happens  that  globules  of  mercury  fall  to  the 
floor  of  the  factory  and  become  a  source  of  danger  to  the  operatives. 
Poisoning  from  this  source  is  not  as  frequent  as  formerly  because  the 
aneroid  barometer  has  displaced  the  mercury  instrument  to  quite  a  large 
extent. 

Mercury  is  also  utilized  to  a  considerable  extent  in  the  manufacture  of 
thermometers.  This  occupation,  which  is  still  carried  on  in  many  cases  in 
dwellings,  is  especially  dangerous  because  it  is  necessary  to  heat  the  mercury 
in  order  to  expel  air  from  the  thermometer  tubes.  In  order  to  prevent  poison- 
ing it  is  essential  to  keep  the  living  quarters  distinctly  separate  from  the 
workshop. 

The  tables  in  the  workshop  should  be  bordered  with  raised  strips  to  pre- 
vent mercury  from  falling  to  the  floor,  and  the  table  board  should  incHne  in 
the  direction  of  a  mercury-catching  receptacle. 

In  the  manufacture  of  incandescent  lamps  vacuum  pumps  are  much 
used.     The  Sprengel  and  similar  air  pumps,  whose  powers  depend  upon  the 


EXPOSURE  TO  OCCUPATIONAL  INTOXICATIONS  525 

fall  of  a  small  stream  of  mercury  through  a  narrow  bore  tube,  are  still  fre- 
quently used.  The  glass  parts  of  the  pumps,  when  broken,  often  become 
a  source  of  danger  — due  to  spillage  of  mercury — -to  the  working  force,  which 
is  composed  chiefly  of  women.  It  is  therefore  important  to  set  up  the  pumps 
on  tables  similar  to  the  ones  described  in  the  section  on  the  thermometer, 
to  prevent  mercury  coming  on  the  floor  and  furthermore  to  replace  as  quickly 
as  possible  all  cracked  parts  of  pumps.  The  Sprengel  pump  in  Germany  and 
America  is  gradually  being  displaced  by  the  rotary  pump,  but  this  too  requires 
mercury  for  its  makeup.  Although  the  danger  of  poisoning  from  breakage 
of  these  pumps  is  not  as  great  as  with  the  Sprengel  pump,  poisoning  can  occur 
when  the  apparatus  is  cleaned.  In  the  rotary  pump  there  is  a  tendency  for 
the  mercury  to  collect  in  the  joints  and  cavities  and  on  the  glass  parts,  but  in 
the  latter  case  it  is  due  to  impurities  in  the  mercury.  The  mercury  of  pumps 
when  impure  must  be  cleansed  by  a  process  of  distillation  or  by  shaking  it  with 
sulphuric  or  nitric  acid.  In  the  first  method  when  the  distilling  apparatus 
is  imperfect  and  allows  the  escape  of  vapors  the  health  of  the  operator  is 
endangered.  In  the  second  method  the  acid  is  removed  from  the  metal  by 
washing  wath  water.  The  water  remaining  incorporated  with  the  metal  is 
removed  by  heating,  in  consequence  of  which  some  of  the  mercury  is  rendered 
volatile.     Here  too  is  a  source  of  poisoning. 

Mercury  pumps  are  also  used  for  exhausting  Rontgen  (X-ray)  tubes. 
In  this  work  the  quantity  of  mercury  employed  is  much  greater  than  is  used 
for  exhausting  incandescent  lamps,  and  the  danger  arising  from  spillage  of 
mercury  and  breaking  of  pumps  is  still  greater.  I  have  seen  the  old  Toepler 
pump  employed  for  this  purpose. 

Inasmuch  as  workmen  engaged  in  the  repair  and  cleansing  of  mercury 
pumps  are  also  exposed  to  the  danger  of  poisoning,  it  is  obvious  that  a  periodic 
change  of  hands  is  indicated.  It  seems  highly  desirable  from  a  hygienic 
standpoint  to  dispense  with  the  use  of  the  mercury  pump  and  to  employ  in- 
stead Geryk  pumps,  such  as  have  been  introduced  into  Germany,  America 
and  elsewhere. 

There  are  also  other  physical  apparatus  in  which  mercury  is  used.  Not- 
ably among  these  are  instruments  for  taking  electrical  measurements. 
English  industrial  inspectors  have  reported  cases  of  poisoning  in  those 
who  use  these  instruments. 

I  have  also  found  numerous  cases  of  poisoning  among  the  help  engaged 
in  making  a  new  kind  of  press  gas  lamp.  By  an  ingeniously  regulated  vola- 
tilization and  recondensation  of  the  mercury  the  pressure  of  the  illuminating 
gas  is  increased  in  the  lamps. 

Of  64  cases  of  mercurialism  reported  in  Great  Britain,  17  occurred  among 
workers  in  electric  meters  and  16  were  engaged  in  the  manufacture  of  philo- 
sophical instruments  (G.  M.  K.). 

In  this  connection  it  may  be  stated  that  Edsall^  relates  the  case  of  two 
dentists  who  contracted  mercurial  poisoning  from  the  habit  of  working  up  the 


526        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

amalgam  in  the  palms  of  their  hands.  He  also  refers  to  a  patient  engaged 
in  working  with  physical  apparatus  and  who  presented  symptoms  of  excessive 
irritabihty  and  apprehensiveness,  also  persistent  diarrhea.  Edsall^  traced 
the  source  of  poison  to  the  fact  that  the  patient  kept  an  open  jar  of  mercury 
on  his  office  desk,  and  frequently  spilled  quicksilver  on  the  floor  of  his  office 
and  bed  room  without  paying  any  attention  to  it.  After  removal  of  the  cause 
the  symptoms  disappeared.     (G.  M.  K.) 

The  Leipsic  morbidity  rate  for  makers  of  instruments  of  precision  is 
955  days  per  annum  per  100  members,  and  the  mortality  hazard  0.78  per 
cent.  (G.  M.  K.). 

Extraction  of  Gold  and  Silver.* — The  property  of  mercury  to  form  an 
amalgam  with  metals,  especially  the  precious  metals,  is  made  use  of  in  the 
extraction  of  gold  and  silver.  In  Europe,  however,  mercury  is  no  longer 
employed  for  extracting  silver,  but  the  process  is  apparently  still  utilized  to 
a  considerable  extent  in  America. 

In  Mexico  the  Patio  or  heap  amalgamation  process  is  still  in  use  to  a 
limited  extent.  In  this  procedure  the  finely  reduced  silver  ore,  placed  in 
large  flat  piles,  is  strewn  with  sodium  chloride,  roasted  chalcoyprite  and 
mercury,  and  mixed  with  a  shovel.  The  heaps  are  then  treated  by  a  burro 
or  kneaded  with  electrically  driven  ploughs.  After  several  weeks  of  this 
kind  of  treatment  the  heavy  amalgam  is  treated  in  agitators  and  settling 
tubs. 

Another  method  of  extracting  silver  is  the  Washoe  or  pan  amalgamation 
process.  Here  moist  ore  is  stamped  to  powder  and  transferred  to  cylindrical 
or  slightly  conical  steam-heated  fans  provided  with  a  device  termed  a 
muller  for  stirring  or  rubbing  the  ore  with  mercury,  copper  sulphate  and 
common  salt.  The  amalgam  is  then  separated  from  the  residue  in  a  settler 
provided  with  an  agitator. 

In  another  process  the  ore  before  amalgamation  is  converted  into  chloride 
by  roasting  it  with  salt  in  a  reverberatory  furnace.  The  silver  chloride  so 
produced  is  then  reduced  with  metallic  iron  or  copper  and  the  silver  is  then 
amalgamated  by  the  Reese-River  pan  amalgamation  process. 

In  all  of  the  processes  discussed  the  silver  must  finally  be  obtained  from 
an  amalgam.  This  is  done  by  diluting  the  amalgam  with  mercury  and  filter- 
ing the  diluted  amalgam  through  canvas.  This  results  in  the  retention  of  an 
amalgam  in  the  canvas  cloth,  which  consists  of  one  part  of  silver  to  seven 
parts  of  mercury.  The  mercury  in  the  retained  amalgam  is  removed  by 
distillation.  During  the  preparation  of  amalgam,  irrespective  of  whether 
it  is  done  in  heaps  or  in  flat  open  pans,  a  volatilization  of  mercury  occurs. 
The  vapor,  as  such,  is  detrimental,  as  already  pointed  out,  from  a  hygienic 
standpoint. 

A  less  dangerous  procedure  seems  to  be  the  water  amalgamation  process 
carried  on  some  years  ago  at  Freiburg,  Saxony.  The  loss  in  mercury,  which 
can  by  no  means  be  all  due  to  volatilization,  in  the  Patio  process  is  1.5  kg. 


EXPOSURE    TO   OCCUPATIONAL   INTOXICATIONS  527 

per  kilo  of  silver;  Burrel  amalgamation  0.22  kg.  per  kilo  of  silver;  and  in  the 
Reese-River  process  0.25  per  ton  of  ore. 

Even  more  dangerous  to  health  is  the  operation  of  removing  mercury  from 
the  amalgam  by  distillation.  This  is  particularly  true  when  leaky  or  other- 
wise inappropriate  distilling  apparatus  are  employed. 

Gold  is  to-day  still  extracted  by  the  amalgamation  method.  In  this 
procedure  mercury  is  added  to  the  finely  reduced  ore,  or  the  amalgamation 
is  done  in  cast-iron  mills  simultaneously  with  the  stamping  (reduction) 
process.  The  latter  process — stamping  mill  amalgamation — is  the  most 
widely  used. 

During  reduction  in  which  powerful  stamping  mills  are  used,  water  flows 
constantly  over  the  ore,  and  mercury  is  introduced  intermittently.  The 
amalgamation  which  occurs  in  the  stamping  troughs  is  accentuated  by 
amalgamated  copper  plates.  Each  day  the  amalgam  is  removed  from  the 
trough;  that  adhering  to  the  copper  plates  is  also  scraped  off  and  treated 
in  a  manner  similar  to  silver  amalgam,  discussed  above. 

Among  other  methods  for  extracting  gold  is  the  cyanide  process  of 
McArthur  and  Forrest.  In  most  cases  this  process  is  preceded  by  a  pre- 
liminary stamping  mill  amalgamation. 

Amalgamation  is  not  resorted  to  in  Europe  for  obtaining  silver,  but  it  is 
apparently  employed  to  a  wide  extent  in  Mexico. 

The  fact  that  gold  and  silver  mines  are  not  usually  located  near  larger 
cites  is  responsible  for  our  lack  of  knowledge  in  regard  to  mercury  poi- 
soning in  this  industry.  We  can,  however,  conclude  from  our  knowledge 
obtained  in  other  vocations,  and  from  the  fact  that  a  large  amount  of  mercury 
is  used  and  the  way  it  is  handled  in  gold  and  silver  extraction,  that  poi- 
soning from  this  source  must  occur  among  the  workmen.  ^lore  informa- 
tion is  required  in  this  direction  and  a  meritorious  piece  of  work  could  be 
done  in  this  connection  by  hygienists  located  near  such  plants  and 
mines. 

Attention  should  also  be  directed  at  this  juncture  to  the  fact  that  there 
are  establishments  engaged  in  extracting  gold  from  the  refuse  of  gold-work- 
ing plants  by  an  amalgamation  process.  Here,  too,  the  mercury  is  re- 
covered by  distillation. 

Fire  Gilding.* — Extensive  use  of  amalgamation  is  made  in  fire  gilding 
(plating).  In  this  process  gold  in  small  pieces  is  heated  in  crucibles  with  8, 
10  and  often  with  15  parts  of  mercury,  and  stirred  with  an  iron  rod  until 
complete  amalgamation  has  taken  place.  The  commodity  to  be  gilded, 
previously  smeared  with  a  solution  of  mercury  in  nitric  or  cyanic  acid,  is 
painted  with  the  amalgam  and  heated  in  an  oven  until  all  of  the  mercury 
is  volatilized.  In  the  preparation  of  the  amalgam,  but  more  especially  in 
heating  the  commodity  coated  with  amalgam,  much  mercury  vapor  is 
developed.  Accordingly  it  is  advisable  in  estabHshments  of  this  kind  to 
install  powerful  suction  fans  for  carrying  oflf  the  vapors.     In  addition   to 


528        ETIOLOGY   AND   PROPHYL.\XIS    OF    OCCUPATIONAL   DISEASES 

taking  precautions  against  mercury  vapors  it  is  also  necessary  to  use  cau- 
tion when  removing  the  commodities  from  the  fire. 

Mercury  when  heated  becomes  more  liquid  (less  viscid)  and  has  a  tend- 
ency to  flow.  Under  these  circumstances  it  is  necessary  to  wipe  the  object 
gilded  with  a  wad  of  cotton  or  brush  in  order  to  distribute  the  amalgam 
more  uniformly  and  to  prevent  bhstering.  In  the  operation  the  eyes  and 
mouth  are  often  brought  into  close  contact  with  mercury  and  its  vapors. 

In  England  the  smaller  commodities  subjected  (uniform  buttons)  to 
amalgamation  are  heated  in  closed  ovens. 

In  the  occupation  of  fire  gilding  (plating)  more  cases  of  acute  mercury 
poisoning,  salivation,  stomatitis,  possibly  gastro-intestinal  manifestations, 
occur  than  in  any  other  calling.  This  is  due  to  imbibing  larger  quantities 
of  mercury  in  a  short  space  of  time.  It  is  obvious  from  what  has  been  said 
that  complete  prevention  of  disease  from  this  source  is  not  possible.  Accord- 
ing to  my  experience  the  number  of  cases  is  relatively  large  among  those 
engaged  in  this  work,  even  though  many  of  the  individuals  work  only  a  few 
hours  each  day  or  only  a  few  days  of  every  week.  Fortunately  the  fire- 
gilding  industry  is  on  the  decline  and  to-day  only  a  few  commodities  are 
plated  by  the  amalgamation  fire  method.  Among  the  commodities  still 
gilded  by  this  method  are  church  crosses,  possibly  cupolas,  lightning-rod 
points,  naval  uniform  buttons  and  articles  in  which  a  special  resistance 
to  the  weather  is  desired.  To-day  plating  is  done  principally  by  the  gal- 
vanic method. 

Manufacture  of  Electrodes,  Storage  Batteries,*  Etc. — A  further  use 
for  amalgam  is  found  in  the  manufacture  of  electrodes.  In  many  cases 
the  zinc  pole  (electrode)  when  kept  in  the  sulphuric  acid  in  the  battery  jar 
will  corrode.  As  a  preventive  against  corrosion  the  electrodes  previously 
cleansed  with  sulphuric  acid  are  coated  (amalgamated)  with  mercury.  In 
this  operation  mercury  is  poured  on  the  plates,  or  the  zinc  electrodes  are 
dipped  into  a  solution  of  mercury  in  nitric  acid  or  nitrohydrochloric  acid. 
Several  cases  of  mercury  poisoning  from  this  source  have  come  under  my 
observation. 

It  should  also  be  mentioned  that  the  rapid  solder  employed  in  storage- 
battery  work  also  contains  mercury.  I  have  also  seen  poisoning  in  those 
who  manufactured  and  made  use  of  such  solder. 

In  manufacturing  storage  batteries  (accumulators)  corrosive  sublimate 
is  added  to  the  plates  in  an  amount  of  30  grams  per  kilo  of  metal. 

Corrosive  subhmate  and  mercuric  nitrate  are  used  for  Damascenizing 
gun  barrels. 

Poisoning  from  sealing  wax  colored  'with  cinnabar  is  also  reported,  but 
to  me  it  seems  improbable.  During  the  preparation  of  fulminate  of  mercury, 
which  is  used  for  making  cartridges,  instances  of  mercury  poisoning  may 
occur.  Poisoning  from  this  source,  however,  is  by  no  means  confined  to 
the  ones  engaged  in  its  manufacture,  in  making  cartridges,  but  it  can  also 


EXPOSURE    TO    OCCUPATIONAL   INTOXICATIONS  529 

affect  the  attendants  of  shooting  galleries  when  the  ventilation  is  bad  and 
where  a  large  number  of  shots  are  fired  in  rapid  succession.  Instances  of 
poisoning  have  also  been  observed  among  the  shooters. 

Mercurial  Chemical  Compounds. f — The  manufacture  of  calomel,  cor- 
rosive subhmate,  nitrate  of  mercury,  red  oxide  and  sulphide  of  mercury  is 
attended  with  more  or  less  danger  from  volatilization  of  the  metal  in  the  sub- 
liming processes  and  likewise  by  the  inhalation  and  absorption  of  mercurial 
dust.  Legge-  found  that  of  27  chemical  workers  4  had  more  or  less  saHva- 
tion  and  10  had  symptoms  of  tremor,  anaemia  and  gastric  derangements. 
He  believes  that  by  the  employment  of  wet  methods  throughout,  most  of 
the  dangers  can  be  ehminated,  especially  if  the  dusty  processes,  such 
as  mixing  and  sieving,  are  done  as  far  as  practicable  by  enclosed 
machinery. 

Mirror  Plating.! — Of  7584  sick  days  among  160  mirror  makers  at  Fiirth 
in  1885,  not  less  than  5463  days  loss  of  work  were  caused  by  mercurial 
poisoning.  This  was  at  a  time  when  mercury  was  poured  as  an  amalgam 
on  a  sheet  of  tin  foil  and  the  glass  plate  placed  over  it  and  weighted  down  so 
as  to  squeeze  out  any  excess  of  mercury.  Dr.  Heucke'^  informs  us  that  this 
process  has  been  almost  completely  replaced  by  the  use  of  a  solution  of  nitrate 
of  silver  containing  an  alkaline  reducing  agent.  The  new  process  is  not 
wholly  free  from  danger,  however,  as  cases  of  lead  poisoning  have  occurred 
from  the  use  of  red  lead  with  which  the  plate  is  backed.  This  danger  can  be 
obviated  by  the  substitution  of  a  coat  of  varnish.  The  use  of  acetaldehyde 
in  connection  with  the  modern  process  of  silvering  mirrors  should  likewise  be 
avoided. 

According  to  Hayhurst,^  nitrate  of  silver  and  tartaric  acid  have  entirely 
supplanted  the  use  of  mercury  in  this  country.  There  is  a  distinct  need  of 
better  ventilation  in  most  of  the  establishments,  especially  for  the  removal 
of  nitric  acid  fumes.  The  temperature  of  the  silvering  rooms  is  often  ex- 
cessively hot  and  the  beveling,  buffing  and  polishing  with  rouge  paste  is 
generally  carried  on  in  rather  damp  places. 

Hatters'  Fur  Cutting,  f — In  the  prehminary  treatment  of  the  fur  for 
the  manufacture  of  felt  hats  the  workers  are  exposed  not  only  to  more  or 
less  dust,  but  also  to  mercurial  poisoning.  The  latter  danger  is  due  to  the 
fact  that  during  the  "carotting  process"  the  fur  side  of  the  pelts  is  brushed 
with  a  solution  of  nitrate  of  mercury.  The  proportion  of  mercury  used  varies 
in  diflferent  establishments.  According  to  Heucke,^  100  kilos  of  the  solution 
contains  about  20  kilos  of  mercury  and  the  average  amount  of  the  metal 
applied  to  each  skin  is  bout  1.64  grams.  Analysis  of  the  dust  and  sweepings 
of  establishments  revealed  the  presence  of  from  0.13  to  1.33  per  cent,  of 
mercury  chloride.  The  solution  generally  employed  in  this  country  is  made 
up  of  4  carboys  of  nitric  acid,  75  lb.  of  mercury  and  50  of  water. 

In  Europe  the  solution  is  usually  composed  of  i  part  of  mercury,  4  parts 
of  nitric  acid  and  20-25  parts  of  water;  in  some  instances  5-6  parts  of  the  acid 
34 


53©        ETIOLOGY   AND   PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

are  used.  The  men  employed  in  making  this  solution  and  those  who  apply 
it  are  exposed  not  only  to  mercury,  but  also  to  nitrous  fumes.  One  of  the 
earliest  manifestations  of  their  combined  action  is  a  greenish  discoloration 
with  subsequent  brittleness  of  the  teeth.  Rubber  gloves  usually  suffice  to 
protect  the  hands  from  the  corrosive  effects  of  the  solution  and  the  absorption 
of  mercury.  With  reasonable  precaution  the  chances  of  mercurial  poisoning 
are  quite  sHght  as  compared  with  the  next  process. 

After  the  application  of  mercurial  solution  the  skins  are  taken  to  special 
drying  rooms  and  their  removal  from  there  is  fraught  with  some  degree  of 
danger,  since  Heim  determined  in  a  cubic  meter  of  air  of  such  rooms  about 
3  cc.  of  nitrous  fumes  and  12.5  mg.  of  mercury.  The  subsequent  storing  of 
the  dried  pelts  is  a  dusty  process  and  increases  the  chances  of  mercurial 
poisoning  with  impregnated  dust.  The  skins  are  next  taken  to  the  brushing 
machine  which  loosens  the  matted  hair,  and  after  cutting  off  the  head,  feet, 
etc.,  they  are  passed  to  the  cutting  machine,  fitted  with  sharp  knives,  which 
shaves  the  fur  from  the  skin.  The  fur  is  then  assorted  by  female  labor,  ac- 
cording to  quality,  color,  and  part  of  the  body,  and  is  then  packed  in  5-lb. 
bundles.  The  brushing  and  cutting  are  both  dusty  processes  and  Heim 
and  Herbert  found  in  the  air  of  the  workrooms  65  mg.  of  dust  with  5  mg. 
of  mercury  per  cubic  meter,  which  sufficiently  emphasizes  the  need  of  efficient 
exhaust  ventilation.  The  fur  from  the  parts  or  trimmings  which  have  been 
cut  off  cannot  be  removed  by  machines  and  this  shearing  is  usually  done  by 
home  hand  labor,  a  most  objectionable  practice,  since  Heim  and  Herbert 
found  in  the  air  of  such  houses  75  mg.  of  dust  with  42  mg.  of  mercury  per 
cubic  meter.  In  some  countries,  notably  Belgium,  most  of  the  processes  are 
carried  on  as  a  home  industry.  As  a  matter  of  fact,  about  four-fifths  of  the 
11,000  to  12,000  furriers  in  Belgium  are  still  home  workers. 

The  sad  effects  of  this  system  have  been  vividly  described  by  Gilbert, 
who  finds  that  one-third  of  the  women  and  over  one-half  of  the  men  employed 
less  than  5  years  suffer  from  mercurial  poisoning.  This  danger  can  be 
readily  appreciated  when  it  is  remembered  that  a  sample  of  the  fur  as  received 
from  the  cutting  machine  was  analyzed  in  the  British  Government  Laboratory 
and  was  found  to  contain  1.34  per  cent,  of  nitrate  of  mercury.  The  mercury, 
according  to  Legge,^  "forms  a  very  insoluble  combination  with  the  keratine 
in  the  hair,  which  is  not  removed  in  the  subsequent  processes  of  felt  hat 
making."  In  view  of  the  fact  that  the  men  who  handle  the  mercurial  solu- 
tion are  exposed  to  the  fumes  and  all  others  engaged  in  dusty  processes  to  the 
inhalation  of  fine  fur  impregnated  with  particles  of  mercury,  it  is  not  surprising 
that  Dr.  Legge  should  have  found  20  of  the  30  employees  in  one  establish- 
ment and  27  out  of  81  workers  in  another  afflicted  with  defective  teeth,  and 
1 7  with  pronounced  mercurial  tremor.  This  same  author,  as  well  as  Tylecote,* 
Teleky  and  J.  H.  Lloyd,  was  among  the  first  to  recognize  that  the  danger 
from  mercurial  poisoning  was  not  confined  to  hatters'  furriers,  but  that  the 
majority  of  cases  actually  occurred  in  felt  hat  makers. 


EXPOSURE   TO   OCCUPATIONAL  INTOXICATIONS  53 1 

Mrs.  L.  W.  Bates^  in  191 2  collected  102  cases  of  mercurial  poisoning, 
occurring  chiefly  in  the  felt  hat  industry  in  New  York  City  and  vicinity; 
she  reports  only  three  cases  in  makers  of  incandescent  electric  lamps,  two 
in  chemists  and  two  in  makers  of  cosmetics. 

The  Felt  Hat  Industry.! — During  the  last  census  year  27,091  persons  were 
employed  in  this  industry  in  the  United  States,  of  whom  25,064  were  wage 
earners.  Of  the  total  number  72.2  per  cent,  were  males  and  27.8  per  cent, 
females;  531  persons,  or  2.1  per  cent.,  were  under  16  years  of  age.  This 
industry  begins  with  the  utilization  of  the  5-lb.  packages  received  from  the 
fur  cutters.  The  fur  of  different  grades  is  mixed  and  thoroughly  picked  and 
separated  in  special  machines,  provided  with  tearing  or  teasing  studded 
wire  teeth,  and  although  these  machines  are  enclosed  and  provided  with 
exhaust  ventilation,  more  or  less  dust  escapes.  The  "blowing  machines" 
are  employed  to  render  the  fur  more  fluffy  and  to  deposit  it,  by  specific 
gravity,  into  graded  bins.  This  process  in  spite  of  enclosed  machinery  is 
very  dusty  and  it  is  believed  that  most  of  the  cases  of  mercurial  poisoning 
originate  in  this  department.  The  subsequent  manipulation  of  forming, 
hardening,  sizing,  shellacing,  blocking  and  dyeing  are  all  wet  processes. 
Much  of  the  work  is  carried  on  in  a  hot  and  moist  atmosphere,  doubtless 
containing  mercurial  vapor.  Over  30  per  cent,  of  the  mercury  cases 
investigated  by  Mrs.  Bates  were  contracted  by  formers,  hardeners  and 
sizers.  Apart  from  mercurial  skin  affections,  the  plankers  and  blockers 
not  infrequently  suffer  from  eczema  and  disfiguration  and  loosening  of  the 
Syfinger  nails,  caused  by  the  use  of  hot  acidulated  water,  or  "planker's  acid.", 
The  stovers,  who  handle  the  hard  felt  shapes  at  a  temperature  of  i8o°F. 
in  the  drying  department,  are  exposed  not  only  to  mercurial  vapors,  but  also 
in  some  establishments  to  the  fumes  of  wood  alcohol,  or  alcohol  denatured 
with  pyridin  bases,  employed  in  the  shellacing  process  to  stiffen  the  hats. 

A  serious  explosion,  resulting  in  the  killing  of  14  persons  and  injuring 
of  50  others,  occurred  at  Denton  in  England  in  1901,  from  the  ignition  of 
spirit  vapor  in  a  drying  stove.  These  dangers  could  be  materially  lessened 
by  the  use  of  drying  chambers,  such  as  are  employed  in  connection  with 
steam  laundries,  provided  with  exhaust  ventilation  and  limiting  the  number 
of  hats  which  could  be  placed  at  one  time  into  the  dryer. 

The  "finishing  or  pouncing  process"  consists  in  smoothing  off  the  coarse 
hair  from  the  surface  of  the  hat,  during  which  a  great  deal  of  very  fine  dust 
impregnated  with  nitrate  of  mercury  is  given  off.  Apart  from  mercurial 
poisoning,  Heinzerling  and  Lewin  cited  by  Schiitte^  have  pointed  out  that 
there  is  also  danger  from  arsenical  poisoning,  since  the  fleshy  part  of  hare  and 
rabbit  skins  is  not  infrequently  treated  with  a  soap,  containing  arsenite  of 
potassium  or  sodium.  The  liability  to  injuries,  especially  with  the  carotting 
machine,  and  to  burns  and  scalds,  should  be  mentioned. 

It  is  very  evident  that  hatters  are  exposed  to  a  very  irritant  dust 
and,  as  a  result,  catarrhal  conditions  of  the_ei:£S.  and  upper  air  passages  and 


532        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

chronic  inflammation  of  the  lungs,  and  pulmonary  tuberculosis,  are  quite 
prevalent. 

Schiittes'  German  statistics^  show  a  morbidity  rate  per  looo  hatters 
as  follows:  diseases  of  the  respiratory  organs  44.1;  pulmonary  tuberculosis 
21.6;  diseases  of  the  eye  and  ear  30;  diseases  of  the  skin  17.1;  injuries 
and  burns  18.1;  industrial  poisoning  22.5;  diseases  of  heart  and  blood- 
vessels 13.9;  diseases  of  the  digestive  organs  28;  diseases  of  the  nervous 
system  21.6.  Apart  from  the  injurious  factors  already  mentioned  the 
unsatisfactory  working  conditions  and  sedentary  habits,  especially  of  the 
female  finishers,  are  doubtless  responsible  for  an  excessive  amount  of 
sickness. 

Hoffman's  Industrial  MortaHty  statistics,  based  upon  832  deaths  among 
hatters,  show  that  278,  or  33.4  per  cent.,  were  caused  by  consumption,  71 
by  pneumonia,  12  by  bronchitis  and  14  by  other  respiratory  diseases,  mak- 
ing a  combined  mortahty  rate  of  45.1  per  cent,  from  diseases  of  the  re- 
spiratory organs.  The  Leipsic  Sick  Benefit  statistics  show  a  very  high  sick- 
ness rate  among  hatters,  viz.,  11 24  days  per  annum  per  100  members,  and 
a  mortality  hazard  of  1.15  per  100  members. 

Preventive  Measures. — The  chief  danger  in  this  industry  lies  in  the  em- 
ployment of  mercury  and  much  attention  has  been  paid  to  provide  a  suit- 
able substitute  for  the  acid  nitrate  of  mercury.  Lussigny  suggested  the 
use  of  a  solution  which  has  for  its  base  caustic  potash.  This  prepara- 
tion has  been  patented  and  is  said  to  have  been  successfully  employed  in 
New  York,  and  by  some  firms  in  Russia,  but  apparently  failed  to  give 
satisfaction  in  France.  Ronzat  has  urged  the  substitution  of  tin  for  mercury, 
and  this  process  is  now  being  tried  in  France,  but  reliable  data  concerning 
the  employment  of  these  substitutes  are  still  wanting.  Until  a  harmless 
substiute  for  mercury  is  generally  adopted,  adequate  exhaust  ventilation 
in  all  processes  involving  the  evolution  of  dust  and  fumes  should  be  insisted 
upon.  This,  together  with  the  wearing  of  rubber  gloves  by  those  handling 
mercurial  solutions,  will  at  least  diminish  the  dangers.  Fortunately,  the 
manufacture  of  wool-felt  hats  has  displaced  to  a  considerable  extent  the 
use  of  rabbit  fur.- 

In  July,  1915,  Commissioner  Lewis  T.  Bryant  of  the  Department  of  Labor 
of  the  State  of  New  Jersey  published  "Sanitary  Standards  for  the  Felt 
Hatting  Industry."  The  report  very  properly  emphasizes  the  chief  health 
hazards,  such  as  mercurial  poisoning,  dust,  humidity  and  other  injurious 
environments,  which  have  combined  to  produce  a  large  number  of  cases  of 
tuberculosis  of  the  lungs.  He  states  that  the  industry  is  regarded  so  dan- 
gerous to  health  that  several  of  the  largest  insurance  companies  refuse  to 
insure  fur  cutters,  makers,  starters  and  sizers  at  any  premium,  and  workers 
in  other  departments  are  charged  an  extra  heavy  premium  on  ordinary 
policies. 

The   general    preventive    measures   and    devices    recommended    in    the 


EXPOSURE  TO  OCCUPATIONAL  INTOXICATIONS  533 

Bulletin  have  been  tried  out  in  different  factories  and  proved  of  value  in 
reducing  to  a  minimum  the  industrial  hazards.  Among  the  important 
measures  recommended  are  that  all  mixing  should  be  done  mechanically 
in  an  inclosed  device,  and  the  fur  mixture  should  be  fed  into  the  "Devil" 
by  means  of  an  inclosed  automatic  device. 

Blowing  machines  should  likewise  be  fed  by  means  of  an  automatic  de- 
vice, and  all  dust  and  fur  fiber  liberated  during  the  blowing  and  cleaning 
operations  should  be  removed  by  means  of  the  exhaust  system,  standard- 
ized in  the  Bulletin.  Vacuum  or  wet  cleaning  only  should  be  employed  in 
the  dusty  departments. 

The  temperature  in  the  blowing  room  and  mill  room  (when  due  to 
artificial  heat)  should  not  be  permitted  to  exceed  75°  and  when  Hve 
steam  is  employed  to  increase  the  humidity,  excess  temperature  should  be 
prevented  by  means  of  a  cold-water  spray  or  other  efficient  methods.  All 
steam  generated  in  the  operations  of  starting,  first  and  second  sizing,  dye- 
ing and  blocking  should  be  controlled  and  eliminated  by  means  of  exhaust 
ventilation.  Wood  alcohol  fumes  should  not  be  permitted  to  pollute  the 
air  of  the  workrooms  either  during,  the  shellacing  or  drying  operations. 
Efficient  means  for  their  removal  should  be  installed,  and  care  exercised  to 
safeguard  against  the  hazard  of  explosion.  All  steam  pots  and  singeing 
flames  should  be  hooded  and  supplied  with  exhaust  ventilation.  All  dust 
generated  in  the  operation  of  pouncing  and  sandpapering  machines  should 
be  removed  by  exhaust  ventilation.  All  hand  or  mechanical  ironing  shells 
should  be  heated  by  electricity.  WTierever  gas  is  employed  for  ironing 
purposes  the  health  of  the  worker  must  be  safeguarded  by  means  of  exhaust 
ventilation.  To  control  the  excessive  heat  generated  in  the  flanging  and 
matricing  operations,  ample  ventilation  by  means  of  windows,  wall  fans  or 
other  devices  should  be  provided;  all  steam  plates  should  be  covered  on 
bottom  and  sides  with  asbestos,  and  whenever  possible  an  electrical  device 
for  heating  the  flange-bags  should  be  installed. 

Standard  safeguarding  should  be  installed  on  all  shafting  under  power- 
driven  serving  machines,  and  on  all  belts,  gears  and  wheels;  and  all  set  screws 
should  either  be  replaced  or  countersunk. 

General  Preventive  Measures  for  Workers  in  Mercury,  t — i .  The  impera- 
tive necessity  of  providing  local  exhaust  ventilation,  wherever  dust  and  fumes 
are  evolved,  as  well  as  a  reduction  of  working  hours  during  the  warm  weather 
should  be  generally  recognized. 

2.  All  processes  involving  the  use  of  mercury  should  be  carried  on  in 
separate  rooms,  with  a  northern  exposure  of  the  windows,  preferably  at  a 
temperature  below  60°,  so  as  to  reduce  the  danger  from  volatilization  of  the 
metal  to  a  minimum.  Work  should  be  suspended  when  the  temperature 
exceeds  78°. 

3.  Wooden  floors  and  work  benches  are  objectionable  as  they  favor  the 
lodgment  of  spilled  mercury  in  cracks  and  crevices.     Enameled  iron  benches 


534        ETIOLOGY   AND    PROPHYL.\XIS    OF    OCCUPATIONAL  DISEASES 

and  smooth  asphalt  floors,  provided  with  an  incline  and  channels  toward 
receptacles  in  which  the  mercury  may  collect  should  be  chosen.  The  recep- 
tacles should  be  covered  leaving  only  a  narrow  opening  just  sufficient  for  the 
metal  to  enter. 

4.  Absolute  care  to  prevent  spilling  of  the  mercury  should  be  exercised 
The  work  benches  should  be  freed  from  the  metal  upon  cessation  of  work, 
the  floors  should  be  sprinkled  and  swept  two  or  three  times  a  day. 

5.  The  workers  should  be  supplied  with  respirators  in  all  dust-producing 
processes;  overalls  and  a  suitable  head  covering  of  a  perfectly  smooth  material 
should  be  used  and  washed  weekly.  The  hair  should  be  worn  closely 
trimmed,  preferably  no  beard;  female  and  youthful  employees  should  be  ex- 
cluded.    The  use  of  alcoholic  beverages  and  tobacco  should  be  prohibited. 

6.  Cleanliness  of  person  and  clothing  are  of  the  utmost  importance.  No 
food  should  be  taken  in  the  workrooms  and  in  no  case  until  after  thorough 
washing  of  the  face  and  hands  with  soap  and  water,  using  a  brush  for  the 
finger  nails,  also  washing  the  mouth  and  teeth  with  brush  and  water,  followed 
by  the  use  of  a  mouth  wash  and  gargle  with  a  solution  of  either  chlorate  or 
permanganate  of  potash  or  phenate  of  sodium.  Heucke  recommends  the  use 
of  akremin  soap,  containing  soluble  alkaline  sulphides,  and  believes  that  the 
wash  water  should  also  contain  potassium  sulphuratum  so  as  to  convert  the 
mercury  into  insoluble  sulphides. 

7.  The  firm  should  provide  not  only  all  the  necessities  referred  to  but  also 
the  facilities  for  warm  shower  and  tub  baths,  suitable  lockers  for  clothing, 
lunch  rooms,  and  periodical  medical  examination  of  the  employees,  with 
suspension  from  work  if  any  are  found  to  present  symptoms  of  mercurial 
poisoning. 

REFERENCES 

1  Edsall,  D.  L.— Jour.  A.  M.  A.,  Vol.  LXXI,  1909,  page  1876. 

2  Legge. — Oliver's  Dangerous  Trades,  London,  1902. 

^  Heucke,  Karl. — 15th  Internal.  Congress  on  Hygiene   and  Demography,  Washington, 

D.,  C,  19T3,  Vol.  Ill,  Part  II,  page  788. 
*  Industrial  Health  Hazards  and  Occupational  Diseases  in  Ohio,  February,  1915. 
^  Legge. — Oliver's  Dangerous  Trades,  London,  1902. 
®  Tylecote,  Frank  E. — 15th  Internal.  Congress  on  Hygiene  and  Demography,  Washington, 

D.  C,  1913,  Vol.  Ill,  Part  II,  page  778. 
^  Mercury  poisoning  in  the  Industries  of  N.  Y.  City  and  vicinity.     Nat.  Civic  Federation, 

Woman's  Welfare  Department,  1913. 
'  Schiitte. — Weyl's  Handbuch  der  Arbeiterkrankheiten,  Jena,  1908,  page  386. 


SECTION  VI 

PROCESSES  INVOLVING  EXPOSURE  TO   POISONING  FROM 
CHEMICALS,  INCLUDING  BENZOL  AND  NAPHTHA 

BY  GEORGE  M.  KOBER,  M.  D..  Washington.  D.  C. 

Sulphuric  Acid.  Hydrochloric  Acid.  Nitric  Acid.  The  Chlorine  Industry.  Iodine  and 
Bromine  Compounds.  Chromium  Compounds.  Calcium  Nitrate.  Manganese. 
The  Coal-tar  Industry.  Benzol.  Nitrobenzol.  Dinitrobenzol.  Aniline.  Di- 
methylaniline.  Trinitrophenol.  Dinitrophenol.  The  Petroleum  Industry.  Dry 
Cleaning  by  Benzine,  etc.  Blanket  Stoving.  The  Paint  and  Varnish  Industry. 
Manufacture  of  Oil  Cloth  and  Linoleum.  Manufacture  of  Straw  Hats.  Manufac- 
ture of  Matches.     Manufacture  and  Use  of  Explosives. 

The  Chemical  Industry. — During  the  last  census  an  average  of  24,876 
wage  earners  was  employed  in  this  industry  in  the  United  States,  of  whom 
23,647  were  males,  1063  females  and  166  boys  and  girls  under  16  years  of 
age. 

Unfortunately  we  have  no  reliable  American  morbidity  and  mortality 
statistics.  The  German  statistics  cited  by  Weyl^  show  that  among  185,820 
employees  in  this  industry  in  1905,  there  were  163,522,  or  88  per  cent.,  cases 
of  sickness,  with  an  average  duration  of  8  days.  There  were  also  11,010 
accidents,  of  which  122,  or  i.ii  per  cent.,  proved  fatal.  The  majority  of  the 
fatal  accidents  were  caused  by  gases,  hot  vapors,  and  the  effects  of  explosions. 
The  statistical  data  by  Leymann^  show  that  the  laborers  and  mechanics  con- 
tributed about  27  per  cent,  and  the  chemists  45  per  cent,  to  the  morbidity  rate 
from  internal  diseases,  and  37  per  cent,  and  43  per  cent.,  respectively,  to  the 
morbidity  from  external  affections.  Diseases  of  the  respiratory  passages  are 
especially  prevalent  among  workers  in  the  manufacture  of  hydrochloric  acid, 
the  sulphates,  chromates,  caustic  potash,  chloride  of  lime  and  trinitrophenol. 
Diseases  of  the  digestive  organs  are  frequent  in  all  chemical  workers,  espe- 
cially among  those  engaged  in  the  manufacture  of  hydrochloric  acid,  soda, 
sodium  sulphates,  chromates  and  aniline  and  in  the  regeneration  of  sulphur. 
Cases  of  poisoning  are  most  frequent  in  the  manufacture  of  aniline.  Burns 
are  most  frequent  in  the  manufacture  of  nitric  acid,  caustic  soda,  chromates 
and  trinitrophenol.  Diseases  of  the  skin  are  most  frequent  in  the  aniline  in- 
dustry and  affections  of  the  eye  in  the  regeneration  of  sulphur. 

Curschmann's^  more  recent  statistics  indicate  that  the  morbidity  rate  in 
the  large  German  Chemical  works  is  54.9  per  cent,  per  annum,  with  an 
average  duration  of  17.8  days.  The  rate  for  female  workers  is  65  per  cent. 
The  mortality  rate  was  only  5  per  1000.  The  morbidity  rate  was  distributed 
as  follows: 

535 


536        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 


Accidents ^^ 

Diseases  of  the  respiratory  organs 16 

Tuberculosis 2 

Diseases  of  the  digestive  system 13 

Rheumatic  affections 8 

Industrial  poisoning o 

Industrial  skin  diseases o 


The  number  of  cases  of  acute  industrial  poisoning  is  not  so  great  as  is 
generally  assumed.  Curschmann  has  tabulated  the  cases  which  occurred  in 
the  German  Chemical  Industry,  1909-1910,  and  reports  50  cases  with  3 
deaths  and  i  permanent  disability  in  the  manufacture  of  aniline,  nitraniline 
and  fuchsin;  29  cases  with  i  permanent  disability  in  the  manufacture  of 
nitro-compounds;  5  cases  in  the  manufacture  of  chloranisidin,  naphthalein 
and  organic  dye  stuffs,  4  cases  with  i  permanent  disability  in  the  manufacture 
of  phosgene;  9  cases  from  salicylic,  oxalic,  phthalic  acid  and  pitch;  30  cases 
in  the  manufacture  of  lead  compounds;  5  cases  in  the  manufacture  of  phos- 
phor trichloride;  8  cases  from  chlorine  and  bromine;  9  cases  with  i  death, 
and  I  permanent  disability  from  nitrous  gases;  12  cases  with  i  permanent 
disability  from  sulphureted  hydrogen;  i  case  from  ammonia;  5  from 
chromium  compounds;  total  167  cases  with  14  deaths  and  5  cases  resulting 
in  permanent  disability. 

About  two- thirds  of  all  the  cases  of  poisoning  occurred  during  the  summer, 
showing  that  a  more  rapid  evaporation,  and  possibly  the  perspiration  and 
exposed  skin  favored  absorption  of  the  toxic  agent,  especially  in  the  manu- 
facture of  dye  stuffs  and  amidobodies.  Of  the  117  cases  of  occupational  skin 
diseases  in  this  tabulation,  74  were  attributed  to  the  misuse  of  chloride  of 
lime  for  cleaning  the  hands;  23  were  produced  by  benzol,  toluol  and  naphthol 
compounds,  and  the  remainder  by  quinine,  tar,  etc. 

Sulphuric  Acid. — Sulphur  dioxide  for  the  manufacture  of  sulphuric  acid 
is  most  generally  obtained  during  the  roasting  of  pyrites  and  various  smelting 
processes  and  is  converted  into  sulphuric  acid  either  in  the  lead  chamber  or 
by  the  contact  process.  The  fumes  are  very  pungent  and  suffocating  and 
doubtless  exert  not  only  irritating  but  also  caustic  effects  upon  the  mucous 
membranes  of  the  upper  air  passages,  and  have  been  known  to  produce 
spasm  of  the  glottis.  According  to  Lehmann,  sulphur  dioxide  in  the  propor- 
tion of  0.03-0.04  per  1000  in  the  air  may  produce  serious  effects  in  persons 
not  accustomed  to  it,  while  old  hands  appear  to  acquire  a  certain  amount  of 
tolerance.  Leymann's  statistics  show  that  diseases  of  the  respiratory  organs 
are  more  frequent  in  sulphuric  acid  workers  than  among  other  chemical 
workers.     Burns  and  injuries  to  the  eyes  from  the  acid  are  not  uncommon. 

Koelsch^  reports  12  cases  of  poisoning  by  sulphur  dioxide  and  sulphuric 
acid  fumes  which  occurred  in  the  German  chemical  industry  in  1907. 
Most  of  these  cases  resulted  from  inhaling  large  quantities,  while  entering  the 
lead  chambers  or  acid  tanks,  or  in  cleaning  out  Gay-Lussac  towers,  or  sul- 


EXPOSURE  TO  OCCUPATIONAL  INTOXICATIONS  537 

phuric  acid  tank-wagons.  In  some  of  these  cases  it  is  not  always  possible  to 
exclude  nitrous  fumes  and  arseniureted  hydrogen.  It  is  important  that  sul- 
phuric acid  should  be  free  from  arsenic.  See  sulphur  dioxide,  sulphuric  acid, 
arseniureted  hydrogen — list  of  industrial  poisons. 

Hydrochloric  acid  is  a  valuable  by-product  of  alkali  works  in  the  manu- 
facture of  sodium  sulphate,  sodium  sulphide,  and  of  soda  by  the  Leblanc  and 
Hargreave's  processes.  The  fumes  of  the  acid  are  very  irritating  and,  even  in 
small  volumes,  may  produce  inflammation  of  the  eyes  and  of  the  air  passages, 
bronchial  catarrh,  coughs,  etc.  In  a  more  concentrated  form  they  have  pro- 
duced caustic  effects  on  the  tips  and  edges  of  the  tongue,  erosions  of  the  teeth, 
and  ulcerations  of  the  nasal  wall.  When  present  to  the  extent  of  2  to  5  volumes 
per  1000  the  lungs  become  distended  with  blood,  and  hemorrhages  from  the 
lungs  and  digestive  tract  are  liable  to  occur.  Lehmann  considers  the  safety 
limit  between  o.i  and  0.2  volume  per  1000,  and  relates  a  case  where 
even  0.5  per  1000  produced  a  violent  reaction. 

In  the  production  of  sodium  sulphate  by  the  Leblanc  process  there  is  a 
possibility  of  exposure  to  the  fumes  of  sulphuric  and  hydrochloric  acid  in  the 
operations  connected  with  the  muffle  furnaces.  In  the  Hargreave's  process 
there  may  be  exposure  to  sulphur  dioxide.  There  is  also  a  possibility  of 
danger  from  sulphureted  hydrogen  during  the  de-arsenicating  process  of  the 
acid  and  in  the  removal  of  the  tank  waste.  Burns  of  the  skin  from  contact 
with  spilled  acid  are  liable  to  occur  and  should  be  promptly  neutralized  and 
washed. 

According  to  Leymann  the  health  of  employees  in  this  industry  is  more 
liable  to  suffer  than  in  the  manufacture  of  sulphuric  or  nitric  acid.  While 
cases  of  acute  poisoning  are  rare,  diseases  of  the  respiratory  and  digestive 
system  and  defective  teeth  are  comparatively  common.  Burns  from 
caustic  soda  occur  in  13.87  per  cent,  of  the  workers  in  that  department,  and 
serious  injuries  to  the  eyes  are  liable  to  occur  from  the  spurting  of  the  strong 
lyes  and  should  be  prevented  by  suitable  eye  protectors.  Diseases  of  the 
digestive  system  are  also  quite  common  in  those  engaged  in  the  manufacture 
of  sodium  compounds. 

Nitric  acid  is  most  commonly  produced  by  the  action  of  sulphuric  acid 
on  saltpeter.  The  decomposition  is  carried  on  in  cast-iron  retorts  and  con- 
densation takes  place  in  fire-clay  Woulff  bottles,  connected  with  a  coke,  or 
a  Lunge-Rohrmann  plate  tower.  The  fumes  of  nitric  acid  and  nitrous  fumes, 
however  generated  (see  list  of  industrial  poisons),  are  very  toxic  and  the 
cases  often  terminate  fatally.  The  fumes  do  not,  except  in  very  concentrated 
volumes,  produce  acute  and  suffocative  attacks  like  those  produced  by  other 
irritant  gases,  and  as  a  result  the  inhalation  may  go  on  for  several  hours  and 
inflict  great  damage  to  the  blood  before  the  appearance  of  serious  symptoms. 
The  literature  contains  numerous  instances  of  poisoning  caused  by  leaky 
retorts,  by  inhaling  the  fumes  in  fiUing  carboys  or  iron  vessels,  by  spilling 
of  the  acid,  breakage  of  carboys  and  attempts  to  mop  up  the  spilled  acid  with 


538        ETIOLOGY   AND    PROPHYLAXIS    OF   OCCUPATIONAL   DISEASES 

saw  dust.  Not  infrequently  these  accidents  are  the  cause  of  fire  and  whole- 
sale cases  of  poisoning  have  occurred  among  the  firemen  as  a  result  of  inhala- 
tion of  nitrous  fumes.  Rambousek^  reports  an  instance  where  between  50 
and  60  carboys  stored  in  an  open  field  caught  fire.  The  15  firemen  ex- 
perienced no  special  discomfort  during  the  half  hour  of  exposure,  but  3 
hours  later  all  had  suffocative  attacks  from  which  one  died  and  the  others 
recovered  after  suffering  from  9  to  10  days  from  affections  of  the  respira- 
tory organs. 

Schultz*  reports  an  instance  in  which  60  firemen,  who  were  fighting  an  ex- 
tensive conflagration  in  a  celluloid  factory,  suffered  from  nitrous  fumes.  The 
autopsy  usually  reveals  intense  inflammation  of  the  mucous  membranes 
of  the  palate  and  upper  air  passages  and  congestion  of  the  lungs.  Czaplewski^ 
describes  several  cases  caused  by  breakage  of  the  carboys  by  carelessly  drag- 
ging them  along  the  floors.  Lewin*  discusses  the  subject  of  nitrous  gas  poison- 
ing in  the  metal  industry  and  proposes  excellent  methods  for  their  prevention. 
The  branches  of  industry  in  which  cases  of  poisoning  are  liable  to  occur  are 
enumerated  in  the  list  of  industrial  poisons,  see  page  734.  Apart  from  the 
serious  effects  referred  to,  the  industry  naturally  involves  exposure  to  burns 
and  predisposes  to  diseases  of  the  respiratory  organs,  which  constitute,  ac- 
cording to  Leymann,  12  and  11.8  per  cent,  respectively  of  the  morbidity. 

Preventive  Measures. — According  to  the  Massachusetts  State  Board  of 
Health^  the  corrosive  acids  are  made  in  such  a  way  that  practically  no  fumes 
whatever  escape,  the  work  being  inclosed  from  beginning  to  end.  In  one 
of  the  largest  chemical  factories  in  that  state,  where  300  men  are  employed, 
it  is  said  that  the  workmen  are  exposed  very  little  to  poisonous  or  irritating 
fumes  and  dust,  or  to  contact  with  poisonous  or  irritating  substances.  At 
certain  points  in  the  building  acid  fumes  in  considerable  strength  are  con>- 
stantly  present,  but  at  these  points  there  is  good  overhead  ventilation,  and 
the  workmen  are  rarely  obliged  to  approach  very  near.  The  utmost  care  is 
required  to  safeguard  the  health  of  the  employees  by  proper  construction  of 
the  apparatus  and  supervision  of  the  various  processes,  so  that  there  may 
be  no  leakage  of  gases.  All  such  processes  should  be  carried  on  under 
official  regulations.  In  the  sulphuric  acid  industry  the  men  who  enter  or 
clean  out  the  chamber  system,  tanks  and  tank  wagons  should  be  provided 
with  smoke  helmets.  Deposits  from  tanks  should  be  either  scooped  out 
without  the  addition  of  water  or  dilute  soda  solution,  or  removed  preferably 
by  means  of  flushing  hose  without  entering  the  tanks. 

In  the  hydrochloric  acid  industry  it  is  important  that  the  salt-coke  pan 
and  reverberatory  furnace  is  properly  constructed.  The  EngHsh  Rules 
provide  that:  i.  The  salt-cake  pan  must  not  be  charged  when  overheated. 
2.  Sulphuric  acid  shall  be  added  only  after  all  the  salt  has  been  charged 
and  the  door  shut.  3.  If  hydrochloric  acid  fumes  escape  at  the  door  when 
the  Glover  acid  flows  in,  the  flow  must  be  interrupted.  4.  All  doors  must  be 
closed  while  work  is  in  progress.     5.  Definite  times  shall  be  fixed  for  with- 


EXPOSURE    TO    OCCUPATIONAL   INTOXICATIONS  539 

drawal  of  the  salt-cake  in  order  to  try  to  ensure  that  it  be  not  still  fuming,  but 
should  this  be  the  case,  cold  sulphate  of  soda,  shall  be  sprinkled  over  it. 

The  Chlorine  Industry. — This  industry  includes  the  production  of  chlorine, 
chiefly  from  manganese  dioxide  by  the  Weldon  process,  the  Deacon  process 
together  with  its  electrolytic  generation  with  simultaneous  production  of 
caustic  alkaH.  It  also  includes  the  manufacture  of  chloride  of  lime,  the 
chlorates  and  hypochlorites.  Chlorine  is  also  used  for  the  production  of  a 
number  of  other  chemical  compounds  which  will  be  alluded  to  later.  In  all 
of  these  processes  there  is  more  or  less  exposure  to  the  inhalation  of  chlorine, 
which  is  most  pronounced  in  the  production  of  chlorine  by  the  Weldon  process, 
and  also  in  the  manufacture  of  bleaching  powder.  Fortunately,  even  the 
smallest  quantities  of  chlorine  cause  suffocative  sensations  which  oblige  the 
workmen  to  leave  the  rooms  and  acute  cases  of  poisoning  are  naturally  rare. 
For  symptoms  and  the  industries  in  which  chlorine  poisoning  may  occur  see 
page  727. 

Exposure  to  the  irritating  fumes  of  chlorine,  even  in  small  volume,  can- 
not fail  to  predispose  to  diseases  of  the  respiratory  organs.  According  to 
Lehmann  o.oi  per  1000  in  the  air  is  injurious,  o.i  per  1000  produces  ulceration 
of  the  mucous  membrane  and  i  or  2  hours'  exposure  endangers  hfe.  Leymann 
states  that  the  morbidity  rates  from  this  class  of  diseases  among  men  engaged 
in  the  manufacture  of  chlorine  and  bleaching  powder  is  17.8  per  cent,  as  com- 
pared with  8.8  per  cent,  in  other  workers.  The  so-called  chlorine  rash  or 
chloracne  is  believed  by  Roth  and  Lehmann  not  to  be  due  to  local  external 
irritation,  but  to  the  excretion  of  chlorine  by  the  skin. 

There  is  also  danger  from  mercurial  poisoning,  if  mercury  is  used  in  the 
electrolytical  production  of  chlorine. 

Iodine  and  Bromine  Compounds. — Chlorine  is  now  very  generally  em- 
ployed to  hberate  iodine  from  the  mother  Uquors  of  Chili  saltpeter  and  other 
salt  industries.  Iodine,  apart  from  its  medicinal  properties,  is  used  in  the 
manufacture  of  iodoform  and  other  pharmaceutical  and  chemical  prepara- 
tions. Ascher  maintains  that  apart  from  exposure  to  chlorine  gas  there  is 
also  danger  from  iodine  poisoning,  affecting  especially  the  nervous  system  and 
not  infrequently  also  resulting  in  gastric  ulcer,  the  effects  being  especially 
marked  in  photographers  who  use  bromide  of  iodine  in  their  work.  Ram- 
bousek^°  cites  two  cases  of  acute  iodine  poisoning  in  a  Swiss  chemical  factory 
where  organic  iodine  compounds  were  made;  one  proved  fatal  and  was  char- 
acterized by  severe  cerebral  symptoms,  giddiness,  double  vision  and  collapse. 

Grandhomme^°has  described  six  cases  of  methyl  iodide  poisoning  among 
workers  engaged  in  the  manufacture  of  antipyrine. 

The  manufacture  of  bromine  compounds  involves  exposure  to  chlorine 
and  there  is  some  evidence  to  indicate  that  there  is  danger  from  bromine 
poisoning.  These  compounds  are  used  not  only  for  medicinal  purposes,  but 
also  in  the  coal-tar  color  industry  and  in  photography.  Schuler,  in  1899 
described  three  fatal  cases  of  methyl  bromine  poisoning  in  men  engaged  in 


540        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

preparing  this  compound  by  means  of  wood  alcohol  and  sulphuric  acid. 
In  all  three  patients  there  were  symptoms  of  nausea,  spasms,  trembling  of 
the  extremities  and  diminished  bodily  temperature.  These  cases  were  re- 
garded as  doubtful,  but  seveial  cases  have  since  been  reported  in  persons 
handling  ethereal  solution  of  methyl  bromide. 

Cases  of  poisoning  have  also  been  reported  in  the  manufacture  and  use  of 
phosphorus  chloride,  sulphur  chloride,  zinc  chloride,  and  even  rock  salt 
has  been  known  to  produce  in  grinders  and  packers,  ulcers  and  perforations 
of  the  nasal  septum. 

Among  the  organic  chlorine  compounds  should  be  mentioned  phosgene, 
which  is  employed  in  the  manufacture  of  different  coloring  material.  Ram- 
busek'"  cites  five  cases  of  industrial  poisoning  and  Grempke^^  reports  three 
fatal  cases  which  were  caused  by  the  escape  of  this  very  toxic  gas  from  leaky 
rubber  tubing  during  its  production. 

Methyl  chloride,  methylene  chloride  and  carbon  tetrachloride  are  also 
poisonous.  In  the  manufacture  of  the  latter  agent  the  workers  are  exposed 
to  the  possible  combined  effects  of  chlorine  and  carbon  bisulphide.  In  the 
production  of  chloroform  there  is  exposure  to  chlorine  and  the  stupefying 
effects  of  chloroform.  Chloride  of  nitrogen  is  said  to  be  very  irritating  and 
is  a  highly  explosive  compound.  Rambousek  mentions  that  there  is  some 
risk  from  the  formation  of  chloride  of  nitrogen  in  the  manufacture  of  gun- 
powder, if  the  nitre  contains  chlorine.  Cyanogen  chloride  is  another  very 
poisonous  chlorine  compound,  and  besides  the  danger  in  its  manufacture, 
Albrecht,  cited  by  Rambousek,  has  pointed  out  that  it  may  also  be  generated 
in  the  production  of  red  prussiate  of  potash,  in  case  the  solution  is  treated 
with  an  excess  of  chlorine.  Rambousek  reports  several  instances  of  industrial 
poisoning  from  hydrofluoric  acid,  some  of  which  occurred  during  its  produc- 
tion, and  presented  evidence  that  the  vapors  exerted  a  corrosive  effect  on 
the  mucous  membrane  of  the  respiratory  passages  and  of  the  eyes.  Blisters 
and  burns,  and  even  deep  ulcers  and  gangrene  of  fingers,  have  resulted  from 
the  topical  use  of  the  acid  in  the  etching  of  glass  (see  also  list  of  industrial 
poisons). 

Preventive  Measures. — The  same  general  principles  which  have  been  enu- 
nciated in  the  manufacture  of  corrosive  acids  apply  to  this  industry  and 
may  be  summed  up  in  careful  supervision  of  all  the  apparatus  and  proc- 
esses, exhaust  ventilation  and  general  cleanliness.  It  is  stated  that  since 
the  use  of  "magnetite"  instead  of  carbon  for  the  anode,  in  the  electrolytic 
production  of  chlorine,  the  number  of  cases  of  chloracne  has  diminished. 
If  this  be  the  case  it  is  a  strong  argument  in  favor  of  the  belief  that  the  tar 
cement  is  a  causative  factor. 

Chromium  Compounds, — Sodium  and  potassium  bichromate  are  exten- 
sively used  in  all  of  the  industries  enumerated  on  page  728. 

Cases  of  poisoning  are  especially  common  in  the  manufacture  of  the  [bi- 
chromates and  may  be  caused  by  the  dust  evolved  in  the  drying,  crushing  and 


EXPOSURE  TO  OCCUPATIONAL  INTOXICATIONS  54 1 

packing  of  these  salts,  and  also  by  the  vapors  from  the  hot  chrome  Uquors. 
The  air  of  a  crushing  room  in  an  establishment,  cited  by  Rambousek,^^  con- 
tained from  3.30  to  6.30  mg.  of  chromate  dust  per  centimeter  and  of  the 
packing  room  1.57  mg.  The  chrome  compounds  not  only  exert  caustic 
effects  upon  the  skin  and  mucous  membranes,  but  also  produce  respiratory 
and  digestive  disorders  and,  by  absorption,  may  even  inflict  serious  damage 
to  the  kidneys.  Eczema  and  characteristic  chrome  ulcers  are,  however, 
the  most  common  manifestations  of  industrial  poisoning.  Leymann's^ 
statistics  show  that  of  722  persons  engaged  in  the  manufacture  of  chromates, 
252  suffered  from  chrome  ulcers  and  perforation  of  the  nasal  septum;  of 
257  workers  observed  by  Hermanni'^  107  had  ulcers  and  87  perforations. 
These  ulcers  are  not  confined  to  the  nose,  but  may  develop  on  the  tonsils, 
palate,  throat,  windpipe,  on  the  arms  and  hands  and  other  exposed  surfaces 
of  the  body.  The  nasal  ulcers  are  doubtless  aggravated  by  picking  with 
fingers.  Diseases  of  the  respiratory  organs  were  observed  by  Leymann  in 
8.8  per  cent,  and  disorders  of  the  digestive  organs  in  12.3  per  cent,  of  his 
cases. 

Cases  of  chrome  poisoning  have  occurred  in  nearly  every  industry  enu- 
merated on  page  728  and  next  to  the  manufacture  of  the  salts,  the  tanning 
industry  and  the  manufacture  of  safety  matches  produce  the  greatest  number 
of  cases.  Occasional  cases  are  also  reported  in  the  calico-printing  and  in  the 
dyeing  industry,  in  glass  workers  and  in  photographers  who  employ  a 
bichromate  developer,  etc.  The  use  of  bichromate  of  lead  involves  an  ad- 
ditional element  of  danger  from  lead  poisoning. 

Preventive  Measures. — -The  machinery  used  for  grinding  the  raw  ma- 
terial, such  as  chrome  ironstone,  lime  and  soda,  and  also  of  the  finished 
product,  should  be  impermeable  and  supplied  with  efficient  exhaust  ven- 
tilation. The  latter  is  also  necessary  wherever  dust  or  steam  is  evolved. 
Respirators,  impermeable  gloves,  anointing  face  and  hands  with  vaseline, 
proper  working  suits  and  caps,  efficient  general  ventilation,  frequent  ablu- 
tions, special  lunch  rooms,  baths,  and  change  of  clothing  upon  cessation  of 
work  are  recommended. 

Frequent  medical  inspections,  prompt  treatment  of  skin  affections 
and  chrome  ulcers,  change  of  work,  and  a  constant  educational  campaign 
will  do  much  toward  the  prevention  of  disabilities. 

Calcium  Nitrate. — According  to  Koelsch,^*  workers  in  factories  where 
calcium  nitrate  is  produced  electrically  from  the  atmosphere  are  subject 
to  a  peculiar  form  of  industrial  poisoning,  which  is  atttributed  to  calcium 
cyanide  in  the  dust  inhaled.  The  symptoms  do  not  develop  until  some 
alcoholic  beverage  is  taken;  then  the  head  becomes  hot  and  flushed  while 
the  limbs  feel  cold.  Pulsation  is  felt  in  the  chest  and  neck,  while  respiration 
becomes  difficult.  Even  minute  quantities  of  alcohol  may  produce  these 
symptoms.  The  face  and  neck  then  become  cyanosed  while  the  trunk  and 
arms  acquire  a  bright  red-colored  rash,  unaccompanied  by  any  great  rise 


542        ETIOLOGY   AXD    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

in  temperature.  The  reflexes  remain  normal,  and  the  senses  are  unim- 
paired. In  severe  cases  giddiness  and  jactation  occur.  The  duration  of 
the  attack  is  variable,  according  to  the  amount  of  alcohol  taken.  When 
vomiting  or  diarrhea  occurs,  instant  improvement  follows,  and  the  rash 
immediately  fades.  No  permanent  ill  effects  have  been  observed  hitherto. 
No  case  of  acquired  immunity  has  been  recorded.  A  few  hours'  stay  in 
the  dusty  factory  is  sufficient  to  render  a  workman  liable  to  attack.  Total 
abstainers  are  not  affected. 

Manganese. — ^langanese  dioxide  or  brown  mineral  occurs  chiefly  as 
a  pyrolusite  and  in  this  country  is  mostly  obtained  from  an  ore  of  which 
zinc  is  the  principal  product.  The  ore  is  run  through  crushers  and  screens 
and  by  means  of  magnetic  belts  those  containing  iron  and  manganese  are 
picked  off,  by  the  belts,  and  deposited  in  bins.  The  crushing,  grinding  and 
sifting  is  a  dry  process  and  the  workers  are  exposed  to  the  inhalation  and 
swallowing  of  this  dust.  Cases  of  manganese  poisoning  have  been  re- 
ported as  incidents  of  this  process,  and  in  the  manufacture  and  use  of  umber 
colors  for  mosaic  work.  Cases  of  poisoning  have  also  been  reported  in 
chemical  factories,  among  men  who  were  engaged  in  the  drying  of  Weldon 
mud,  the  dioxide  of  manganese  having  been  used  for  the  recovery  of  chlo- 
rine by  the  Weldon  process.  Manganese  is  also  used  for  the  production  of 
potassium  permanganate,  and  in  the  manufacture  of  glass,  as  a  coloring 
and  decolorizing  agent;  it  is  likewise  employed  in  the  ceramic  industry  for 
coloring  and  glazing  purposes  and  as  a  drier  in  the  varnish  and  oil  in- 
dustry. The  literature  contains  only  between  25  and  30  cases  of  industrial 
manganese  poisoning,  but  it  is  highly  probable  that  such  instances  are 
much  more  frequent  than  is  commonly  assumed.  It  is  believed  that  man- 
ganese and  its  compounds,  in  the  form  of  dust,  especially  when  rich  in 
manganese  protoxide  may  produce  the  intoxications  described  on  page  119. 

Apart  from  the  nervous  and  locomotor  disturbances  described  by  Casa- 
major  and  other  writers,  Neisser^^  refers  to  headache,  dizziness,  loss  of 
appetite,  constipation,  loosening  of  the  teeth,  lancinating  muscular  pains 
and  general  debility,  as  symptoms  observed  in  some  of  the  workers  in  man- 
ganese. The  possibility  of  a  combination  of  manganese  and  zinc  poisoning 
should  be  considered. 

Preventive  Measures. — Improved  methods  for  the  arrest  of  dust  at  the 
place  of  origin  by  inclosed  machinery,  its  efficient  removal  by  exhaust  fans, 
together  with  respiratory  masks,  suitable  clothing,  facilities  for  ablutions, 
mouth  washes  and  gargles  before  meals,  supplemented  by  shower  baths  and 
change  of  clothing  upon  cessation  of  work,  should  be  insisted  upon. 

COAL-TAR  DISTILLATION  PRODUCTS  OR  DERIVATIVES 

The  manufacture  of  coal-tar  products  affords  employment  to  a  large 
number  of  wage  earners,  who  are  exposed  to  more  or  less  dangerous  agents. 


EXPOSURE  TO  OCCUPATIONAL  INTOXICATIONS         543 

Coal  Tar. — Coal  tar  is  obtained  by  dry  distillation  of  coal  and  is  an 
important  by-product  of  illuminating  gas  and  coke  works.  It  is  chiefly 
used  for  the  production,  by  fractional  distillation,  of  so-called  coal-tar  prod- 
ucts, such  as  benzene,  toluene,  naphthalene,  anthracene,  carbolic  acid, 
pyridine,  etc.,  from  which  again  are  made  saccharine,  various  drugs,  dyes, 
perfumes,  etc.  About  50  per  cent,  of  the  coal  tar  is  pitch  and  remains  in 
the  stills  as  a  residue.  This  substance,  like  tar,  is  used  in  the  manufacture 
of  varnishes,  metal  paints,  artificial  fuel  (briquets),  etc.  Crude  tar  is  also 
used  for  preserving  wood  in  the  manufacture  of  roofing  paper,  in  the  con- 
struction of  asphalt  pavements,  etc.  The  constitutional  efifects  of  inhala- 
tion of  tar  vapors  are  such  as  loss  of  appetite,  nausea,  diarrhea,  headache, 
vertigo,  catarrhal  conditions  of  the  upper  air  passages.  In  some  instances, 
however,  ischuria,  strangury,  albuminuria  and  oedema  have  developed, 
rarely  of  a  serious  nature.  Affections  of  the  skin,  such  as  eczema,  pimples 
and  psoriasis  are  quite  frequent  among  workers  in  tar,  and  may  affect  not 
only  the  hands  and  arms,  but  also  other  parts  of  the  body.  Cancroid 
ulcers,  especially  of  the  scrotum,  are  liable  to  develop  not  only  among 
workers  in  the  tar,  lamp  black  and  paraflSne  industry  but  also  in  chimney 
sweepers  and  briquet  makers. 

Benzol. — This  important  coal-tar  derivative  is  secured  by  fractional 
distillation  of  tar  in  wrought-iron  stills.  Crude  benzol  consists  chiefly 
of  benzene  and  toluene.  Pure  benzene  and  pure  toluene  are  secured  by 
additional  fractional  distillation.  Benzol  is  placed  on  the  market  as 
90  per  cent,  and  50  per  cent,  benzol,  and  as  solvent  naphtha.  Pure  benzene 
vapors  are  very  poisonous.  The  limit  for  animals  is  between  0.015  ^^^ 
0.016  per  1000.  For  symptoms  and  branches  of  industry  in  which  benzol 
is  employed  and  poisoning  may  occur  see  page  724. 

Dr.  Rambousek^^  reports  34  cases  of  benzol  poisoning  of  which  24  were 
acute  cases  and  proved  fatal.  About  one-half  of  the  cases  occurred  in 
connection  with  benzene  plants,  either  during  the  distillation  process,  or 
during  the  cleaning  out  of  the  extraction  apparatus,  or  storage  and  trans- 
portation tanks.  Twelve  cases  occurred  in  the  rubber  industry,  one  in 
the  manufacture  of  antipyrine;  one  in  a  painter  while  applying  a  coat  of 
asphalt  paint  to  the  interior  of  a  large  iron  tank,  in  which  benzol,  instead  of 
turpentine,  was  used,  and  three  cases  occurred  in  a  color  factory,  from  the 
internal  use  of  alcohol  denatured  by  the  addition  of  i  to  2  per  cent,  of  benzol. 

A  case^^  of  chronic  industrial  poisoning  by  xylene,  a  homologue  of 
benzol,  is  referred  to  as  having  occurred  in  the  rubber  industry;  also  a  case 
of  carbon  monoxide  poisoning  and  several  from  sulphureted  hydrogen  gas 
in  coal-tar  distillation. 

In  the  coal-tar  distillation,  at  a  temperature  of  i5o-2oo°C.,  the  middle 
oil  passes  over.  This  contains  naphthalene,  which  upon  cooHng  crystallizes 
out,  and  after  washing  with  caustic  soda  and  acid,  is  redistilled  and  hot 
pressed.     From  the  remaining  liquor,  phenol  or  carbolic  acid  is  obtained. 


544        ETIOLOGY    AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

This  serves  as  the  basis  for  various  chemical  and  pharmaceutical  prepara- 
tions, such  as  salicylic  acid,  picric  acid,  etc.  The  heavy  oils  which  pass 
over  at  a  temperature  between  200  and  3oo°C.  are  rich  in  cresols,  naphthols, 
naphthalene  and  fluid  parafline,  from  which  lysol  and  other  disinfectants 
may  be  obtained.  But  the  bulk  of  the  heavy  oils  are  used  for  preservation 
of  railway  ties,  shingles,  etc.  Raw  anthracene  oil,  or  green  oil,  passes  over 
between  300°  and  4oo°C.  and  is  also  used  as  a  wood-preserving  paint  or 
stain.  The  alizarin  dyes  are  made  from  the  anthracene  extracted  from  this 
oil.  Workers  in  anthracene  are  subject  to  severe  skin  affections  which 
occasionally  develop  into  cancer  (Rambousek).^*  Cases  of  industrial  phenol 
poisoning  are  said  to  be  rare.  Apart  from  the  effects  upon  the  skin,-  WeyP^ 
states  that  chronic  symptoms,  such  as  vomiting,  difficulty  in  swallowing, 
increased  flow  of  saliva  and  chronic  nephritis,  have  been  observed  among 
surgeons  and  workers  in  the  manufacture  of  carbolized  dressings.  Pyridine 
is  used  for  denaturing  alcohol  and  the  eczematous  condition  of  the  skin  in 
persons  using  denatured  alcohol  is  probably  caused  by  pyridine. 

The  coal-tar  color  industry  is  based  upon  the  employment  of  the 
hydrocarbon  compounds  such  as  benzene,  toluene,  xylene,  naphthalene, 
anthracene,  phenol  and  cresoles.  Other  agents  employed  are  wood  alcohol, 
ethyl  alcohol,  phosgene  and  formaldehyde,  nitric  acid,  sulphuric  acid,  caustic 
soda,  chlorine  and  bromine.  All  of  the  nitro  derivatives  are  obtained  by  the 
action  of  a  mixture  of  nitric  and  concentrated  sulphuric  acid  on  any  one  of  the 
hydrocarbons  of  the  benzene  series. 

Nitrobenzol,  also  known  as  myrbane  oil,  or  imitation  bitter  almond  oil, 
is  an  intermediate  product  in  the  manufacture  of  aniline,  and  is  secured  by 
the  action  of  sulphuric  and  nitric  acid  upon  benzene,  thus  forming  nitro- 
benzol. Toluene  and  xylene  are  nitrated  with  the  same  acids.  The  dinitro 
products  are  obtained  by  further  action  of  nitro-sulphuric  acid  on  the  mono- 
nitro-compound  at  a  higher  temperature.  All  nitro-compounds  of  benzol 
and  its  homologues,  such  as  dinitrobenzol,  dinitrochlorobenzol,  nitrotoluol, 
nitrophenol,  nitronaphthalene,  etc.,  are  more  or  less  poisonous.  Cases  of 
poisoning  from  these  agents  have  been  reported  in  the  coal-tar  industry  and 
estabhshments  in  which  its  intermediate  products  are  manufactured  or 
handled,  such  as  in  the  manufacture  of  aniline,  explosives,  perfumery,  soap, 
pharmaceutical  preparations,  etc. 

Grandhomme^*'  has  reported  60  cases  of  industrial  poisoning  by  nitro- 
benzol, of  which  24  or  42  per  cent,  proved  fatal;  4  cases  resulted  from  inhala- 
tion and  in  55  cases  the  agent  entered  the  system.  Dr.  S.  S.  Adams-^  reports 
15  cases  with  3  deaths  in  which  the  agent  was  taken  into  the  mouth;  6  cases 
with  2  deaths  were  caused  by  inhalation;  2  cases,  i  fatal,  in  which  nitrobenzol 
was  absorbed  by  the  skin;  2  cases,  i  in  which  the  agent  was  used  with  suicidal 
intent;  and  3  cases  with  2  deaths  in  which  nitrobenzol  was  taken  to  induce 
abortion.     Of  the  28  cases,  9  were  typical  occupational  intoxications. 

Dinitrobenzol  is  the  combustible  ingredient  of  roburite  and  other  high 


EXPOSURE  TO  OCCUPATIONAL  INTOXICATIONS  545 

explosives.  Oliver^^  reports  a  case  in  which  a  man  engaged  in  cleaning  out 
the  air  flue,  from  which  the  fumes  from  three  mixing  pans  were  discharged, 
in  spite  of  respirator  and  rubber  clothing,  was  fatally  injured  by  the  fumes. 
The  majority  of  workers  in  dinitro-compounds  in  Great  Britain  show  evidence 
of  chronic  intoxication.  Of  20  examined  in  explosive  works,  14  presented  a 
bluish-gray  color  of  the  lips  and  face,  10  were  profoundly  anaemic  and  6 
suffered  from  slight  tremblings  and  other  nervous  affections. ^^ 

Aniline,  also  known  as  aniline  oil,  is  a  colorless  fluid  which  upon  exposure 
to  light  and  air  gradually  becomes  dark  in  color.  It  is  produced  by  the  action 
of  hydrochloric  acid  and  iron  filings  upon  pure  nitrobenzol,  and  like  all  other 
compounds  of  benzol  and  its  homologues,  such  as  toluol,  naphthalene,  xylol, 
is  a  blood  and  nerve  poison.  Poisoning  may  occur  in  the  manufacture  of 
aniline  and  its  derivatives,  such  as  aniline  dyes,  pharmaceutical  preparations, 
photographic  materials,  etc.,  and  in  dyeing  establishments.  The  poison  may 
be  absorbed  through  the  skin  by  direct  contact  or  from  saturated  clothing,  by 
inhalation  of  vapors  and  impalpable  dust,  and  also  by  way  of  the  digestive 
tract.  The  symptoms  may  be  acute,  subacute  and  chronic,  and  will  be 
described  on  page  721. 

Dimethylaniline  is  produced  by  heating  aniline,  aniline  hydrochloride 
and  wood  alcohol.  Diethylaniline  is  prepared  in  the  same  way  except  that 
ethyl  alcohol  is  used.  The  nitroso-compounds  are  produced  by  the  action  of 
nitrous  acid  (sodium  nitrite  and  hydrochloric  acid)  on  the  acid  solution  of 
diethylaniline. 

Trinitrophenol  or  picric  acid  is  produced  by  the  action  of  nitro-sulphuric 
acid  upon  phenol.  In  a  pure  state  it  forms  pale  yellow  crystals  and  is  ex- 
tensively used  as  a  yellow  dye  stuff,  and  also  as  an  ammonia  compound  in 
the  manufacture  of  explosives  (lyddite,  melinite).  It  enters  the  body  in  the 
form  of  dust,  by  inhalation,  and  also  exerts  an  irritant  effect  on  the  skin, 
mucous  membrane,  intestinal  canal  and  upon  the  kidneys.  Dinitrophenol 
may  cause  acute  symptoms  of  industrial  poisoning  similar  to  those  ob- 
served from  nitrobenzol. 

Leymann,  cited  by  Rambousek,^*  describes  cases  where  the  workers  were 
suddenly  stricken  with  symptoms  of  collapse,  vomiting,  pains  in  the  chest, 
difficult  breathing,  rapid  pulse,  convulsions  and  death  within  a  few  hours. 
The  autopsy  revealed  a  yellow  substance  with  picric  acid  reaction,  which 
appeared  to  be  di-  or  trinitrophenol.  In  cases  of  nitrochlorobenzene  poison- 
ing Leymann  noted  the  typical  gray-blue  discoloration  of  the  skin,  and  the 
chocolate-brown  color  of  the  blood  produced  by  methemoglobin. 

Space  will  not  permit  reference  to  other  coal-tar  color  products  such  as 
the  azo  dye  stuffs,  anthracene  colors,  alizarin  dyes,  indigo,  fuchsin,  methyl 
violet  and  sulphur  dyes. 

Resume  of  the  Dangers  in  this  Industry. — Much  has  been  done  in  the 
last  two  or  three  decades  to  clear  up  many  misconceptions  as  to  the  dangers 
attending  the  production  of  aniline  and  other  coal-tar  colors.  According 
35 


546        ETIOLOGY    AND    PROPHYL.\XIS    OF    OCCUPATIONAL   DISEASES 

to  Grandhomme^  and  Curschmann,-^  the  raw  product  benzol  probably  caused 
the  greatest  number  of  cases  of  industrial  poisoning.  The  statistics  are  not 
wholly  clear  since  a  great  many  authors  fail  to  differentiate  between  petroleum 
and  coal-tar  benzene.  The  manufacture  of  the  intermediate  group,  especially 
the  nitro-  and  amido-compounds,  involves  considerable  risk.  Curschmann 
mentions  particularly  nitrobenzol,  chloronitrobenzol  and  dinitrochloro- 
benzol.  Grandhomme^*  has  observed  no  injurious  effects  from  naphthalene 
and  anthracene  and  considers  the  danger  in  the  manufacture  of  fuchsin,  of 
the  blue  dahlias,  greens,  resorcin,  eosin  and  the  alizarin  colors  and  phar- 
maceutical compounds  comparatively  slight.  He  mentions  arsenic  and  ar- 
seniureted  hydrogen  as  possible  sources  of  danger  in  the  manufacture  of 
fuchsin  and  of  the  methylene  blue,  and  reports  42  cases  of  aniline  poisoning 
in  one  of  the  chemical  works  within  3  years,  with  no  fatalities.  Professor 
Roth^''  refers  to  the  fact  that  in  1905  not  less  than  38  cases  of  diseases  of  the 
bladder,  mostly  sarcoma  and  cancer,  occurred  among  the  workers  in  a 
German  aniline  factory  in  the  vicinity  of  Frankfort.  Schwerin  claims  that 
tumors  of  the  bladder  are  quite  common  in  that  vicinity,  but  on  the  whole 
it  must  be  conceded  that,  since  the  poisonous  agents  are  largely  eliminated 
through  the  kidneys,  the  irritant  eflfects  upon  the  mucous  membrane  of  the 
bladder  cannot  be  questioned,  especially  since  strangury  is  a  frequent 
symptom  in  chronic  anilismus.  It  is  very  likely  that  some  of  the  skin 
affections  are  also  caused  by  the  elimination  of  the  poisonous  substances 
through  the  perspiration. 

Cases  of  aniline  poisoning  are  not  infrequent  in  other  industries,  especially 
in  dye  works.  Lymann^^  reports  four  fatal  cases  of  poisoning  in  the  manu- 
facture of  black  dyes  from  mono-  and  dinitrophenols  and  nitrochlorobenzene 
and  toluene  compounds. 

White  and  Sellers^®  report  a  fatal  case  of  acute  aniline  poisoning  in  a 
worker  who,  while  preparing  aniline  hydrochloride  (used  for  dyeing  yarn 
with  aniline  black),  spilled  a  quantity  over  his  hands,  face  and  upper  part  of 
the  body,  and  died  within  less  than  24  hours.  Neisser^"  reports  a  number  of 
cases  of  aniline  poisoning  which  occurred  in  different  industries,  such  as  wood 
staining  in  imitation  of  mahogany,  and  describes  the  case  of  a  Swiss  dyer  who, 
in  opening  an  iron  drum,  spilled  a  quantity  of  aniline  oil  which  saturated  part 
of  his  clothing.  He  continued  work  for  several  hours.  The  case  resulted  in 
insanity  and  impairment  of  vision.  Cases  of  aniUsm  have  been  reported  in 
black  dyeing  establishments  and  in  cloth  pressers  working  with  black  dyes. 

Senn^^  has  reported  a  typical  bronzing  of  the  skin  with  a  dark  brown 
discoloration  and  inflammation  of  the  cornea  occurring  among  men  exposed 
to  the  hot  vapors  from  an  aniline  black  dye  mixture,  composed  of  aniline, 
hydrochloric  acid  and  potassium  chromate,  known  as  "chinon."  Hanke^^ 
has  observed  cases  of  inflammation  and  opacity  of  the  cornea  caused  by 
continued  exposure  to  the  vapors  of  nitronaphthalene  or  to  spurting  of  the 
liquid  into  the  eye. 


EXPOSURE  TO  OCCUPATIONAL  INTOXICATIONS  547 

Preventive  Measures.— The  coal-tar  industry  requires  careful  technical 
and  medical  supervision  to  safeguard  the  health  of  the  wage  earners.  The 
distillation  of  tar  and  the  purification  and  cooling  of  the  distillation  products 
must  be  carried  on  in  properly  constructed  stills,  apparatus  and  vessels 
provided  with  facilities  for  the  removal  of  injurious  gases,  and  all  leaky  or 
defective  apparatus  should  be  promptly  remedied.  In  the  coal-tar  color 
industry  we  have  to  deal  not  only  with  the  toxic  properties  of  the  raw  material 
such  as  benzene  and  toluene,  but  also  with  the  intermediate  products  such  as 
nitrobenzol,  aniline,  toluidine.  Many  of  the  processes  involve  exposure  to 
chlorine,  acids,  especially  nitric  acid,  and  sulphuretted  hydrogen  gas 
and  other  chemical  agents,  which  must  be  guarded  against  by  enclosed  proc- 
esses and  mechanical  suctional  ventilation  for  the  removal  of  toxic  fumes 
and  dust.  In  addition  to  these  devices,  the  general  ventilation  of  the  es- 
tablishment should  be  perfect.  All  sweeping  and  cleaning  should  be  done 
by  the  vacuum  system.  General  and  personal  cleanliness  are  of  the  utmost 
importance.  The  men  should  wear  suitable  eye  protectors,  work  in  special 
suits,  frequently  washed,  and  eat  in  special  lunch  rooms.  Frequent  ablutions 
of  the  hands,  especially  before  meals,  and  a  bath  with  change  of  clothing  upon 
cessation  of  work  are  essential.  The  workmen  should  receive  systematic 
instruction  in  the  prevention  of  accidents,  in  first  aid,  the  employment  of 
respirators,  pulmotors,  oxygen  inhalation  etc.  These  measures,  with  careful 
periodical  physical  examination  of  the  employees  by  a  full-time  salaried 
physician,  have  proved  in  large  establishments  of  immense  value  to  aU 
concerned.  Curschmann,  with  his  large  experience  in  the  "de  Greppin 
works,"  also  emphasizes  the  importance  of  good  wholesome  food,  abstinence 
from  alcoholic  beverages,  sanitary  homes  for  the  wage  earners  and  a  careful 
selection  of  the  employees  engaged  in  this  industry. 

The  Petroleum  Industry. — During  the  last  census  year  the  number  of 
persons  in  the  U.  S.  engaged  in  the  refining  of  crude  petroleum  was  16,640, 
of  whom  159  were  women  and  43  persons  under  16  years  of  age. 

Employees  in  the  petroleum  industry  are  exposed  to  the  gases  evolved 
from  the  oil,  namely,  benzine,  or  petrol  naphtha.  The  men  near  the  wells 
and  pumps  and  those  who  enter  the  tanks  or  clean  out  the  retorts  are 
especially  exposed  to  concentrated  petroleum  vapors. 

Refining  of  Crude  Petroleum. — Hayhurst^^  states  that  in  receiving  the 
crude  product,  usually  by  pipe  lines,  there  was  an  odor  of  hydrocarbons 
(methane  ?)  and  of  hydrogen  sulphide  present  in  some  places,  but  not  hazard- 
ous except  when  leaks  occurred,  and  that  cases  of  sore  eyes  were  not  infrequent. 
The  distilling  and  refining  of  crude  petroleum  includes  purification  with 
sulphuric  acid  and  its  neutralization  with  caustic  soda,  de-colorization  with 
Fuller's  earth  and  de-odorization  with  hydrochloric  acid  and  chloride  of  lime, 
and  hence  involves  exposure  to  these  industrial  poisons. 

The  residuum  of  American  oil  is  especially  rich  in  paraffine,  vaseline  and 
other  lubricants  which  are  extracted  by  different  processes.     In  some  places 


548        ETIOLOGY  AND   PROPHYLAXIS   OF    OCCUPATIONAL  DISEASES 

where  the  retorts  are  opened  for  the  removal  of  the  residue  there  is  consid- 
erable exposure  to  sulphur  dioxide,  and  in  the  recovery  of  tar  there  is 
generally  exposure  to  sulphuric  acid  fumes.  Lead  oxide  is  also  added  to  the 
oil  and  the  men  who  shovel  it  into  the  open  vats  and  those  obliged  to  repair 
lead-lined  tanks  are  exposed  to  the  risk  of  lead  poisoning.  There  is  also 
considerable  exposure  to  dust  in  the  de-sulphurizing  process,  in  which  a 
mixture  of  copper,  lead  and  iron  oxides  is  used. 

Filtering  and  Pressing. — In  this  department  the  residue  is  separated 
into  heavy  oils,  greases  and  paraffine.  The  work  is  carried  on  at  a  tem- 
perature of  5o°F.  The  paraffine  is  extracted  by  means  of  big  presses  and 
conveyed  by.  machine  work  to  a  chamber  where  it  is  heated  and  filtered. 
Exposure  to  ammonia  fumes  from  the  cooling  plant  is  noted  in  the  Ohio 
Survey,  and  also  a  vile  stench  from  the  boiling  down  of  wool  greases  to  be 
added  to  the  lubricating  oils. 

It  is  very  likely,  as  pointed  out  by  Dr.  Wm.  H.  Sharp, ^^  that  the  toxic  effects 
of  petroleum  vapors  vary  with  the  character  of  the  oil,  heavy  oils  producing 
mild  attacks  while  the  light  oils  may  result  in  asphyxia.  Some  of  the  crude 
oils  cause  irritation  of  the  respiratory  passages,  while  others  affect  the  central 
nervous  system. 

Petroleum  as  a  fluid  has  a  direct  action  on  the  skin,  and  persons  engaged 
in  the  filling  of  barrels,  emptying  retorts,  and  handling  of  paraffine  and  other 
residues  are  liable  to  develop  obstinate  inflammatory  conditions  of  the  skin 
— the  so-called  petroleum  and  paraffine  itch — also  pimples,  pustules,  boils  and 
warty  growths.  MitchelP^  was  among  the  first  to  call  attention  to  these  skin 
affections.  Similar  effects  are  produced  in  furniture  polishers,  machine  oilers 
and  all  others  who  handle  either  crude  petroleum  or  paraffine,  unless  protected 
by  impermeable  gloves.  The  literature  contains  numerous  references  to  cases 
of  poisoning  among  persons  employed  in  petroleum  and  naphtha  tanks,  in 
cleaning  out  railway  oil  tanks,  in  the  use  of  petroleum  motors  and  in  the 
refining  of  naphtha,  as  a  result  of  inhalation  of  the  light  oils,  benzine  and 
gasoline.  The  employment  of  benzine  as  a  motive  power,  as  a  cleaning  agent, 
in  dry-cleaning  establishments,  as  a  solvent  of  rubber  and  fats,  and  as  a  sub- 
stitute for  turpentine  in  the  manufacture  of  paints,  varnishes,  lacquers,  etc., 
is  constantly  widening  the  chances  for  acute  or  chronic  forms  of  petroleum 
and  benzine  poisoning. 

Berthenson^"  deplores  the  scarcity  of  reliable  morbidity  statistics  in  this 
industry,  but  reports  that  of  8465  employees  treated  at  Baku  (Russia)  there 
were  12 16  cases  of  diseases  of  the  skin  and  subcutaneous  cellular  tissue,  696 
burns,  1475  cases  of  catarrhal  affections  of  the  upper  air  passages,  34  cases  of 
croupous  pneumonia,  29  of  catarrhal  pneumonia,  36  of  pleurisy,  5  of  pul- 
monary tuberculosis,  and  607  cases  of  muscular  rheumatism.  He  also  cites 
Petkewitch's  observation  that  quite  a  number  of  employees  purposely  exposed 
themselves  to  the  intoxicating  vapors  of  petroleum.  The  German  statistics 
presented  by  WeyF^  show  that  of  1380  employees  in  petroleum  refineries 


EXPOSURE  TO  OCCUPATIONAL  INTOXICATIONS  549 

9  cases  of  poisoning  and  34  cases  of  acne  were  reported  in  the  course  of  a  few 
years. 

Preventive  Measures. — The  utmost  care  should  be  taken  to  secure  effi- 
cient removal  of  concentrated  petroleum  vapors  from  tanks  and  stills  by 
means  of  compressed  air,  steam  or  oxygen.  Careful  supervision  of  the  work, 
impermeable  gloves,  personal  cleanliness  by  means  of  frequent  ablutions  of 
the  hands,  shower  baths,  and  change  of  clothing  upon  cessation  of  work  are 
indicated.  Suspension  of  work  upon  appearance  of  toxic  symptoms  should 
be  insisted  upon.  (For  further  details  and  preventive  measures  see  page 
136,  735-) 

Dry  Cleaning  by  Means  of  Benzine,  Chemicals,  Etc. — So-called  "  chemical 
cleaning  establishments"  are  often  carried  on  in  connection  with  dye  works 
which  make  a  specialty  of  renovating  wearing  apparel,  etc.  The  processes 
and  chemical  agents  employed  are  quite  varied.  Apart  from  the  dyes  men- 
tioned on  page  655,  various  iron  salts  such  as  acetate,  nitrate  and  sulphate, 
and  copper  sulphate  are  used.  Alum  is  employed  as  a  mordant  and  per- 
manganate of  potassium  as  an  oxidizing  agent;  acetic,  hydrochloric,  oxalic, 
and  sulphuric  acids  are  likewise  employed.  Borax,  caustic  potash,  soap  and 
sodium  bisulphide  are  used  for  washing  and  bleaching  purposes. 

The  principal  agents  for  the  removal  of  stains  are  benzene,  naphtha,  wood 
alcohol  and  ammonia;  potassium  cyanide  removes  silver  stains  and  oxalic 
acid  removes  ink  and  rust  stains. 

In  the  cleaning  process  soiled  gloves  and  garments  are  usually  placed  in 
a  large,  revolving,  hermetically  closed  cylinder  containing  either  naphtha  or 
benzine,  with  or  without  the  addition  of  soap.  After  the  first  cleaning  the 
articles  are  placed  in  naphtha  alone.  After  the  second  rinsing  the  clothing 
is  placed  in  a  centrifugal  machine  for  the  removal  of  surplus  benzine,  etc., 
and  then  taken  to  the  drying  room  which  is  kept  at  a  temperature  of  between 
ioo°-i20°F.  On  account  of  the  inflammable  character  of  the  benzine  vapors 
present  extreme  caution  is  necessary,  in  all  processes,  to  avoid  naked  flames, 
matches  or  other  igniting  agents.  The  naphtha  fumes  in  the  drying  depart- 
ment in  spite  of  mechanical  ventilation  are  very  strong,  and  according  to  the 
Massachusetts  State  Board  of  Health, ^^  "the  men  employed  are  pale  and 
some  of  them  markedly  sick  looking;"  some  of  the  men  are  occasionally 
overcome  by  the  fumes,  or  have  shown  the  characteristic  excitement  and  hys- 
terical symptoms  of  benzene  or  naphtha  intoxication.  The  presence  of  vapor- 
ized gasoline  is  frequently  noted  in  the  pressing  department,  where  the  irons 
are  heated  by  means  of  gasoline  gas. 

Carpet  Cleaning. — Some  of  the  establishments  also  conduct  a  rug  and  car- 
pet cleaning  department,  which  is  usually  equipped  with  an  enclosed  dusting 
machine,  exhaust  fans  and  dust  flues.  The  introduction  of  vacuum  cleaners 
has  rendered  this  operation  less  dusty  and  harmful,  but  the  danger  from  the 
employment  of  benzine  and  benzol  for  the  removal  of  stains  has  not  dimin- 
ished. 


550        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

Apart  from  the  cases  of  poisoning  already  referred  to  on  page  137,  543, 
Dr.  \Neisser^'  reports  an  instance  in  a  carpet  cleaning  establishment  of 
Berlin  where  large  quantities  of  benzine  had  been  used.  Three  of  the  work- 
men were  found  unconscious  upon  the  floor  and  were  with  difiiculty  resus- 
citated by  the  inhalation  of  oxygen. 

"Blanket  Sieving. " — This  occupation  is  of  interest  chiefly  because  the 
blankets  are  bleached  by  means  of  sulphur  fumes.  It  is  generally  held  that 
the  men  who  are  engaged  in  this  work  are  not  especially  liable  to  tuberculosis 
and  other  infectious  diseases,  but  those  exposed  to  the  inhalation  of  sulphur 
fumes  and  to  abrupt  changes  in  temperature  not  infrequently  suffer  from 
chronic  bronchitis  and  emphysema  of  the  lungs. 

Preventive  Measures. — It  is  needless  to  insist  that  wherever  benzine  and 
benzol  vapors  are  developed  they  should  be  immediately  removed  by  ade- 
quate exhaust  ventilation.  This  is  demanded  not  only  in  the  interest  of 
wage  earners,  but  also  as  a  safeguard  against  fire.  All  machines  containing 
benzine  or  benzol  should  be  furnished  with  hermetically  closed  covers,  to  be 
removed  only  for  such  time  as  may  be  necessary  to  feed  or  remove  the  articles 
to  be  washed.  Substitution  for  benzine  of  less  toxic  agents,  such  as  carbon 
tetrachloride,  has  been  urged  (Rambousek*°).  The  same  general  principles 
apply  to  the  removal  of  dust  or  sulphur  fumes  in  carpet  cleaning  and  blanket 
bleaching  establishments. 

The  Paint  and  Varnish  Industry. — -During  the  last  census  21,896  persons 
were  engaged  in  the  paint  and  varnish  industry  of  whom  19,496  were  males 
and  2400,  or  II  per  cent,  females.  The  statistics  cover  the  returns  of 
two  classes  of  establishments,  viz.,  those  engaged  primarily  in  the  manufacture 
of  pigments  or  paints  and  those  engaged  in  the  manufacture  of  varnishes, 
japans,  lacquers  or  fillers.  The  principal  products  of  the  latter  class  are 
mainly  solutions  of  gums,  resins,  asphaltum,  or  other  ingredients,  in  such 
solvents  or  vehicles  as  turpentine,  linseeed-oil,  alcohol,  benzine,  benzene,  etc. 

The  Massachusetts  State  Board  of  Health'*^  in  discussing  the  manufac- 
ture of  paints,  colors  and  varnishes,  points  out  that  much  of  the  work  is 
done  by  men,  who  have  worked  from  6  to  20  yeas;  the  man  who  makes  the 
lead  colors  has  worked  17  years  without  sickness.  The  last  case  of  poi- 
soning occurred  16  years  ago,  when  a  number  of  inexperienced  men  were 
poisoned  with  Paris  green.  In  a  color  and  mordant  factory,  where  aniline 
colors,  logwood,  starch,  sodium  dichromate,  etc.,  are  used,  about  one  in 
five  of  the  employees  was  noticably  pale  and  sallow,  and  inflamed  eyes, 
caused  by  the  sodium  dichromate,  were  not  uncommon.  In  the  manu- 
facture of  "whiting"  about  half  of  the  58  men  employed  in  three  establish- 
ments visited  "looked  to  be  in  poor  condition."  In  making  shingle  stains 
pigments,  like  chromate  of  lead,  Prussian  blue,  zinc  and  iron  oxide,  are  first 
mixed  or  ground  with  linsecd-oil  or  with  creosote  or  some  of  the  "heavy 
or  light  oils."  In  two  of  the  establishments  the  men  appeared  to  be  care- 
less in  the  matter  of  handling  the  pigments. 


EXPOSURE   TO    OCCUPATIONAL    INTOXICATIONS  551 

Manufacture  of  Linseed-oil,  Dryers,  Varnishes,  Japans,  Etc.— Linseed- 
oil  is  extracted  from  linseed  previously  heated  and  crushed  and  submitted 
to  3500  lb.  pressure  in  hydraulic  presses.  The  temperature  in  the  press 
rooms  often  reaches  above  i25°F.  Refined  linseed-oil  is  obtained  by  treat- 
ing the  raw  and  filtered  oil  in  lead-lined  tanks  with  a  10  per  cent,  solution  of 
strong  sulphuric  acid.  Dryers  and  fillers  are  usually  made  by  boiling  lin- 
seed-oil with  some  oxidizing  substance,  such  as  oxide  of  lead,  manganese, 
etc.  During  the  boihng  of  hnseed-oil,  acrolein  vapors  and  considerable  heat 
are  evolved,  which  should  be  carried  off  by  means  of  hoods  and  exhaust 
ventilation. 

Varnishes  are  solutions  of  various  gums  and  oleoresins  dissolved  in 
alcohol  and  turpentine.  Unfortunately,  quite  commonly,  benzene,  ben- 
zine and  wood  alcohol  are  substituted  as  solvents.  Among  the  many  var- 
nishes may  be  mentioned  asphalt,  Burmese,  copal,  dammar,  mastic,  spar, 
and  wax  varnishes.  Shellac  dissolved  in  alcohol  or  wood  alcohol  is  most 
frequently  used  for  wood  work.  Thompson'*^  states  that  orpiment  is 
occasionally  employed  to  make  poor  grades  of  shellac  yellow  and  opaque. 
Copal  and  asphaltum  varnishes  are  most  commonly  employed  as  a  lacquer 
for  metal  work.  Zapone  lacquer,  which  is  a  solution  of  celluloid  in  amyl 
acetate  and  acetone,  is  employed  in  various  industries,  chiefly  as  a  lac- 
quering agent  in  metallic  ware  and  jewlery  factories.  Unfortunately,  we 
have  no  morbidity  and  mortality  statistics  of  these  industries. 

The  Ohio  Survery  of  1914  by  Hayhurst  covered  40  establishments 
with  757  men  engaged  in  these  processes.  The  investigation  disclosed 
22  positive  and  4  tentative  cases  of  lead  poisoning,  and  5  positive  cases  of 
benzine  poisoning.  Among  the  common  personal  complaints  were  nausea, 
loss  of  appetite,  dizziness,  restless  sleep,  trembling,  palpitation,  frequent 
urination,  headache,  constipation,  eczema  and  inflamed  eyes.  All  of  these 
symptoms  can  be  reasonably  attributed  to  the  effects  of  injurious  dusts, 
fumes  and  vapors. 

Preventive  Measures. — Acrolein,  amyl  acetate,  benzene,  benzine,  lead 
compounds,  manganese,  pitch,  turpentine  and  wood  alcohol  are  industrial 
poisons,  and  the  workers  should  be  protected  by  adequate  ventilation  dur- 
ing not  only  the  manufacture  but  also  the  use  of  the  agents  containing  them. 
It  should  also  be  remembered  that  all  quickly  drying  spirit  or  inflammable 
paints  and  varnishes  are  not  only  a  source  of  benzine  and  wood  alcohol 
poisoning,  but  may  be  the  cause  of  serious  burns  from  ignition  of  the  vapors 
by  a  naked  flame.     (See  also  painting.) 

Manufacture  of  Oil -cloth  and  Linoleum. — This  industry  is  inimical  to 
health  on  account  of  a  number  of  injurious  factors  connected  with  the  dif- 
ferent processes  of  its  manufacture.  Linoleum  is  made  by  spreading  a 
mixture  of  oxidized  linseed-oil,  resin  and  ground  cork  over  a  rough  ground 
texture  of  cloth,  which  is  varnished  on  its  lower  surface.  It  is  made  either 
in  one  color  or  in  patterns.     The  patterns  according  to  Doehring*^  are  pro- 


552        ETIOLOGY   AND   PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

duced  in  three  ways:  (i)  By  the  appHcation  upon  the  ground  texture  of  a 
mixture  of  covering  masses  of  different  colors  and  grain;  (2)  by  the  juxta- 
position and  fastening  of  differently  colored  and  arranged  patterns  upon  the 
ground  texture;  (3)  by  printing  the  plain  linoleum  with  oil  colors.  The 
resulting  products  are  known  as  grain,  inlaid,  and  printed  hnoleum.  The 
colors  often  contain  arsenical,  lead  and  mercurial  pigments.  It  may  be 
said  that  the  covering  mass  of  linoleum  consists  chiefly  of  an  intimate  mixture 
of  oxidized  linseed-oil  (linoxyn)  and  finely  ground  cork  meal.  The  latter 
is  obtained  from  the  waste  material  of  the  cork  industry,  cut  up  and  ground 
into  a  very  fine  powder  by  suitable  machines  and  rollers.  This  gives  rise 
to  large  volumes  of  light  floating  dust,  and  although  morbidity  statistics 
are  not  available,  there  is  every  reason  to  believe  that  it  is  liable  to  produce 
diseases  of  the  respiratory  passages.  Indeed  the  cork  industry  in  general, 
such  as  making  cork  soles  and  corks  for  bottles  has  long  since  been  regarded 
as  a  very  dusty  trade.  Apart  from  the  danger  of  dust  inhalation  cork  dust 
is  highly  inflammable  and  explosions  have  occurred  not  only  during  the 
grinding  operations,  but  also  during  the  subsequent  mixing  processes. 

For  the  purpose  of  making  linoxyn  the  linseed- oil  to  which  certain  oxi- 
dizing substances  such  as  litharge,  sugar  of  lead,  oxide  of  zinc,  superoxide  of 
manganese,  etc.,  have  been  added  is  usually  boiled  at  a  temperature  between 
392°  and  464°F.  This  may  be  done  in  open  or  hooded  vessels;  in  either 
case  frequent  stirring  is  necessary  to  secure  a  thorough  admixture  of  the 
oxidizing  agents,  and  to  prevent  excessive  heating  of  the  oil  on  the  walls  of 
the  utensil.  This  involves  not  only  exposure  to  excessive  heat  and  frequent 
burns  but  also  to  the  inhalation  of  acrolein  and  other  industrial  poisons. 
As  a  matter  of  fact  inflammatory  conditions  of  the  mucous  membrane  of  the 
eyes,  nose  and  upper  air  passages  are  not  uncommon.  When  the  oxi- 
dized linseed-oil  is  ready  for  use,  it  is  mixed  in  a  steam-heated  vessel  with 
38  parts  of  resin,  13  parts  of  Cowrie  or  New  Zealand  gum,  and  some  suit- 
able coloring  material.  This  mass  is  next  thoroughly  mixed  with  an  equal 
weight  of  cork  meal,  in  a  suitable  mixing  machine.  Benzine  and  turpen- 
tine are  sometimes  used  to  render  the  mass  more  plastic  and  less  brittle. 
As  substitutes  for  cork,  wood  flour,  pulverized  peat  or  other  vegetable 
fiber  have  been  used  and  in  place  of  linseed-oil,  the  distillation  residue  of 
palm  and  cotton-seed  oil  are  employed.  The  addition  of  resin  to  hot  linseed- 
oil  develops  volatile  substances.  The  ether  oil  which  forms  is  said  to  pro- 
duce headache,  nausea  and  sometimes  complete  stupor.  Diseases  of 
the  upper  air  passages,  chronic  bronchial  catarrh  and  even  hemoptysis 
may  be  produced  according  to  Eulenberg  by  the  inhalation  of  these  volatile 
vapors.  Workers  in  resin  arc  also  liable  to  eczema  and  other  affections  of 
the  skin. 

The  next  process  in  the  manufacture  of  linoleum  consists  in  the  applica- 
tion of  the  covering  mass  (heated  to  a  temperature  between  280°  and  3oo°F.) 
to  the  ground  texture,  by  means  of  plate  and  roller  presses,  which  are  hollow 


EXPOSURE    TO   OCCUPATIONAL   INTOXICATIONS  553 

and  heated  by  steam  under  pressure.  The  other  processes  are  the  cooHng 
of  the  mass  on  cold  rollers  and  the  drying  of  the  linoleum  in  special  rooms 
at  a  temperature  between  77°  and  86°.  The  pattern  printing  is  usually 
done  by  means  of  forms  of  wood  or  metal  forms  upon  printing  presses  or 
machines  in  oil  colors  which  not  infrequently  contain  toxic  pigments.  The 
linoleum  receiving  the  patterns  is  again  placed  in  the  drying  rooms  and  when 
completely  dried,  it  is  cut,  the  upper  surface  is  washed  and  occasionally 
receives  a  coat  of  zapone  lacquer. 

Preventive  Measures. — Adequate  provisions  should  be  made  in  the  way 
of  hoods  and  exhaust  ventilation  for  the  removal  of  dust  and  fumes;  the 
latter  on  account  of  their  offensive  character  should  be  conducted  to  the 
furnace  fires  and  burnt  up,  or  into  the  smoke  stacks  and  discharged  at  great 
heights.  Mechanical  stirrers  should  replace  the  hand  ladles.  Since  cork 
dust  explosions  are  often  caused  by  particles  of  iron-producing  sparks  in 
passing  through  the  mills,  Doehring^^  recommends  passing  the  cork  through 
a  magnetic  separator  before  being  placed  on  the  comminuting  machine. 

Manufacture  of  Straw  Hats. — The  employees  in  this  industry  are  ex- 
posed not  only  to  the  inhalation  of  dust  and  unfavorable  working  conditions, 
but  also  to  a  number  of  toxic  agents  in  the  bleaching,  varnishing,  sizing, 
staining  and  blocking  processes.  The  stock  is  most  commonly  bleached  by 
exposure  to  sulphur  fumes  in  special  chambers,  and  unless  all  fumes  are 
driven  off  before  the  doors  are  opened  the  persons  who  remove  the  stock  are 
subject  to  inhalation  of  these  fumes. 

Bleaching  is  also  accomplished  by  immersion  of  the  stock  for  several 
hours  in  a  solution  of  bisulphate  of  sodium,  zinc  dust  and  hydrochloric  acid, 
or  by  the  employment  of  a  bath  of  oxalic  acid,  tartaric  acid,  acetic  acid, 
sodium  peroxide  and  hydrogen  peroxide.  After  removal  of  the  braid  from 
the  bath,  the  stock  is  placed  in  a  drying  room.  The  varnishing  process  with 
shellac  dissolved  in  wood  alcohol,  and  staining  process  with  aniline  in 
wood  alcohol,  involves  exposure  to  the  toxic  fumes  of  this  agent.  The 
persons  employed  in  sizing  the  hats  with  glue  are  exposed  to  excessive  heat, 
since  a  temperature  of  about  ioo°F.  appears  necessary  "in  order  that  the  glue 
may  run  off  freely."  The  girls  who  trim  the  hats  often  occupy  a  stooped 
position.  The  general  working  conditions  of  all  the  employees  should  be 
improved  by  adequate  air-space,  exhaust  ventilation  and  proper  lighting. 
(See  also  felt  hat  industry.) 

The  Manufacture  of  Matches. — The  dangers  from  chronic  phosphorus 
poisoning  in  this  industry,  when  white  phosphorus  is  used,  has  been  pointed 
out  on  page  145.  It  is  simply  a  question  of  time  when  this  danger  will  be 
wholly  eliminated  by  the  general  substitution  of  red  phosphorus,  and  the 
manufacture  of  so-called  safety  matches. 

The  ordinary  process  involves  fixing  the  matches  in  frames  and  dipping 
the  ends,  first  into  paraffine  or  sulphur  and  afterward  in  the  phosphorus 
paste,  consisting  of  a  solution  of  gum  or  dextrine  and  yellow  phosphorus. 


554        ETIOLOGY   AND   PROPHYLAXIS    OF   OCCUPATIONAL  DISEASES 

containing  also  some  oxidizing  agent  such  as  red  lead,  nitrate  of  lead,  man- 
ganese dioxide  or  niter.     The  matches  are  then  dried  and  packed. 

The  preparation  of  the  paste,  dipping,  drying  and  packing  involves  the 
greatest  occupational  risks  and,  although  all  these  processes  can  be  carried 
on  automatically  by  American  machinery,  it  did  not  prevent  to  any  con- 
siderable extent  the  occurrence  of  poisoning;  hence  the  act  imposing  a  tax 
of  2  cts.  per  hundred  upon  matches  made  with  white  phosphorus  which 
went  into  effect  July  i,  1913,  and  which  is  practically  a  prohibitive  act. 

The  paste  for  safety  matches  consists  of  potassium  chlorate,  sulphur,  or 
antimony  sulphide,  potassium  bichromate  and  glass  powder,  mixed  in  a 
solution  of  gum  or  dextrine.  The  matches  are  saturated  with  parafl&ne  or 
phosphate  of  ammonia.  The  friction  surface  for  these  matches  is  made  up 
of  a  mixture  of  dextrine,  antimony  sulphide  and  red  phosphorus,  the  latter, 
on  striking,  acts  as  the  igniting  agent. 

Some  authorities  maintain  that  the  use  of  red  phosphorus  is  not  free 
from  danger,  but  in  France  no  cases  of  poisoning  have  occurred  since  the 
use  of  white  phosphorus  was  forbidden  in  1898. 

The  manufacture  of  Swedish  safety  matches,  when  chrome  salts  are  used 
in  the  paste,  has  given  rise  to  chrome  ulcers  and  severe  eczema.  Wodtke^* 
reports  18  perforations  of  the  septum  nasi  among  84  workers.  For  preventive 
measures  see  Phosphorus,  page  153;  Chromium  compounds,  page  541. 

THE  MANUFACTURE  AND  USE  OF  EXPLOSIVES 

Explosive  compounds  are  used  not  only  for  the  purpose  of  propelling 
projectiles  from  firearms,  but  also  for  the  explosion  of  shells,  torpedoes, 
mines  and  blasting  operations  of  all  kinds.  The  principal  propelling  agent 
employed  up  to  1845  was  gunpowder,  but  since  that  time  new  cofnpounds 
have  sprung  into  existence,  many  of  which  are  known  as  high  explosives  and 
fulminates. 

According  to  "  Cundill's  Dictionary  of  Explosives,"  cited  by  Prof .  Munroe** 
there  were  upward  of  1000  explosives  in  1895,  which  have  materially  in- 
creased in  number  since. 

Gunpowder. — -The  ingredients  in  gunpowder  are  7 5  to  76  parts  of  saltpeter, 
14  to  15  of  charcoal  and  10  of  sulphur.  Slightly  different  proportions  are  used 
in  various  countries.  Gunpowder  explodes  at  a  temperature  of  about  7oo°F. 
The  force  of  the  explosion  resulting  from  the  production  of  gases  expanded 
by  the  intense  heat  developed  by  the  chemical  action  of  the  combustible 
ingredients  with  the  niter,  varies  with  the  conditions  under  which  it  is  fired, 
the  density  of  the  gunpowder  and  the  shape  and  size  of  the  individual  grains. 

The  force  of  an  explosion  from  gunpowder  may  become  intelligible  when 
we  realize  that  according  to  some  authorities  there  are  a  million  foot-tons  of 
energy  per  second  for  each  ton  of  powder.  Black  blasting  powder  in  this 
country  contains  about  73  parts  of  sodium  nitrate,  16  parts  of  charcoal  and 


EXPOSURE  TO  OCCUPATIONAL  INTOXICATIONS  555 

II  parts  of  sulphur.  According  to  Munroe  no  marked  changes  have  been 
made  in  the  manufacture  of  or  composition  of  gunpowder  or  blasting  powder, 
but  the  latter  has  new  competitors  in  the  composition  made  by  mixing  finely 
divided  metals,  such  as  aluminum  or  alloys,  ferrosiUcon,  with  potassium  or 
sodium  nitrate  or  other  oxidizing  agents. 

Dr.  E.  R.  Hayhurst"  investigated  seven  estabUshments  for  the  manu- 
facture of  explosives  in  Ohio  and  the  following  is  a  brief  summary  of  his  find- 
ings. The  actual  number  of  persons  employed  was  303  wage  earners  of 
whom  51  were  females.  The  general  appearance  of  workers  was  fair  to  good 
in  four  places,  but  a  considerable  number  of  unhealthy  men  were  found  in 
some  of  the  processes  in  two  places. 

In  the  grinding  rooms  some  of  the  men  complained  that  the  nitrate  caused 
headaches  and  dizzy  feelings  at  times,  hence  the  machines  should  be  properly 
enclosed.  The  pulverizing  of  charcoal  was  exceedingly  dusty  and  complaints 
of  bronchitis  were  made.  The  grinding  of  cakes  of  finished  powder  is  usually 
done  in  isolated  places,  the  workmen  being  provided  with  small  sheds  to 
avoid  danger  from  explosion  while  the  grinding  is  going  on. 

In  the  incorporating  mills  the  work  is  extremely  dirty  and  care  must  be 
taken  to  see  that  the  charge  does  not  work  out  from  under  the  grinding 
wheels,  otherwise  the  wheel  may  cause  contact  with  the  base  and  form  a  spark. 
Since  explosions  are  especially  liable  to  occur  in  this  process,  water  is  thrown 
on  constantly  to  keep  the  charge  cool.  The  work  in  the  press  rooms  where 
the  pulverized  charge  is  pressed  into  flat  cakes  by  hand  or  machine  presses 
is  attended  with  the  production  of  considerable  amount  of  dust.  The  same 
is  true  of  the  operations  of  the  corning  mills,  which  reduce  the  powder  to 
the  proper-sized  grains.  The  glazing  of  the  grains  of  powder  with  lead  sul- 
phide and  graphite  appears  to  be  free  from  risk  of  lead  poisoning,  although 
some  of  the  w^orkmen  had  bad  teeth.  The  separating,  weighing  and  packing 
operations  appeared  to  be  free  from  hazards. 

Fulminating  powder  is  used  for  charging  percussion  caps  and  parlor  rifle 
shells,  detonators  and  electric  detonators.  It  is  composed  of  about  35  parts 
of  fulminate  of  mercury,  16  of  chlorate  of  potassa,  45  of  glass  dust,  2  of  gum 
arable  and  2  of  gum  tragacanth.  These  are  mixed  by  using  the  fulminate 
in  a  moist  state.  It  explodes  readily  by  percussion  and  by  friction  or  by  a 
heat  of  367°F.  The  manufacture  of  fulminate  of  mercury  which  is  made  by 
dissolving  mercury  in  nitric  acid  and  adding  alcohol,  is  attended  with  the 
evolution  of  injurious  fumes  containing  according  to  Rambousek'*^  ethyl 
acetate,  acetic  acid,  ethyl  nitrate,  nitrous  acid,  and  volatile  hydrocyanic 
acid  compounds. 

Apart  from  the  inflammabihty  of  these  vapors  which  have  been  the  cause 
of  fires  and  accidents,  "their  inhalation  is  liable  to  cause  headache,  vertigo, 
loss  of  consciousness,  numbness  of  the  extremities  and  a  sense  of  constriction 
of  the  chest  which  may  be  accompanied  by  cyanosis"  (Oliver).-*^ 

In  the  manufacture  of  percussion  caps,  there  is  also  danger  of  mercurial 


556        ETIOLOGY   AND    PROPHYL.\XIS    OF    OCCUPATIONAL   DISEASES 

poisoning;  about  40  per  cent,  of  the  females  employed  in  a  Nuremburg  fac- 
tory are  reported  to  have  suffered  from  mercurial  poisoning,  due  according  to 
Heinzerling  to  the  inhalation  of  mercury  fumes  developed  by  tiny  explosions 
in  the  pressing  and  filling.  Neisser*^  also  reports  cases  which  occurred  in  a 
factory  at  Marseilles  in  1907. 

Preventive  Measures. — It  is  needless  to  insist  that  in  the  manufacture 
of  fulminate  of  mercury,  the  dangerous  gases  like  nitrous  fumes,  cyanogen, 
and  acetic  acid  compounds  are  promptly  removed  by  efiScient  exhaust 
ventilation.  The  persons  employed  should  be  skilled  and  realize  the  danger, 
both  as  to  explosion  and  as  to  poisoning. 

Gun  Cotton  or  Pyroxyline. — Ever  since  its  discovery  by  Schonbein  in 
1846  attempts  have  been  made  to  use  it  as  a  substitute  for  gunpowder,  be- 
cause its  projectile  force,  when  used  in  moderate  charges  is  equal  to  about 
twice  its  weight  of  the  best  gunpowder.  Its  explosive  force  is  also  very  much 
more  intense  than  that  of  gunpowder  and  in  this  respect  its  nature  is  similar 
to  the  fulminates.  Gun  cotton  explodes  at  a  temperature  of  about  277°?. 
and  evolves  little  or  no  smoke  as  the  principal  residue  of  its  combustion  is 
water  and  nitrous  acid.  It  is  made  by  immersion  of  cotton  wool  in  strong 
nitric  and  sulphuric  acids  in  so-called  nitrating  centrifugal  machines.  The 
danger  from  explosion  was  very  great,  when  drying  stoves  were  employed, 
but  this  has  been  overcome  by  using  alcohol  in  dehydration.  Gun  cotton 
is  used  in  the  manufacture  of  smokeless  powder  and  also  as  a  charge  for  tor- 
pedoes and  submarine  mines. 

Collodion  cotton  is  prepared  in  a  similar  way  as  gun  cotton,  except  that 
the  acids  are  weaker,  and  the  product  is  a  partially  nitrated  cellulose.  When 
dissolved  in  alcohol-ether  it  is  known  as  collodion,  which  is  extensively  used 
in  surgery,  photography  and  in  the  manufacture  of  celluloid,  artificial  silk, 
gas  mantles,  moving-picture  films  and  other  pyroxylin  plastics. 

In  the  manufacture  of  gun  cotton  and  collodion  cotton  the  chief  danger 
to  the  workmen  are  the  fumes  of  nitric  acid  and  nitrous  fumes,  but  with  good 
air-tight  machines  these  risks,  and  subsequent  erosions  of  the  incisor  teeth 
have  been  greatly  diminished.  There  is  also  danger  from  explosions  in  the 
drying  process  as  evidenced  by  the  accidents  reported  by  Marshall.  ^° 

In  the  manufacture  of  collodion,  celluloid  and  artificial  silk  the  workmen 
may  also  be  exposed  to  ether,  alcohol,  acetone,  acetic  ether  and  camphor, 
but  Rambousek  found  no  cases  of  such  poisoning  in  the  literature  of  the 
subject. 

Preventive  Measures.— In  the  preparation  of  gun  cotton  and  collodion, 
it  is  important  that  the  acid  fumes  from  the  nitrating  and  centrifugalizing 
machines  are  carried  off  by  earthenware  ducts  and  fans,  and  that  the  bulk 
of  the  acid  is  removed  by  centrifugal  action.  Cleanliness  and  efficient 
exhaust  ventilation  should  be  insisted  upon  in  all  the  processes. 

Smokeless  Powder. — ^This  explosive  is  derived  from  gun  cotton  or  other 
forms  of  nitrocellulose  and  is  gelatinized  by  the  addition  of  alcohol-ether,  or 


EXPOSURE    TO    OCCUPATIONAL   INTOXICATIONS  557 

acetone,  camphor,  resin,  etc.  The  resulting  paste  or  dough  is  then  rolled, 
washed,  dried  and  pressed  into  rods.  According  to  Marshall,  "the  press 
most  commonly  used  is  an  adaptation  of  the  machine  employed  for  making 
macaroni.  The  resulting  product  is  in  the  form  of  cords,  strips  or  tubes, 
which  can  be  cut  into  flakes  of  any  desired  thickness."  It  is  of  interest 
to  note  that  the  first  successful  smokeless  powder  was  made  in  1865  by 
Captain  Schultze  of  the  Prussian  Artillery  from  nitrated  wood,  instead 
of  nitro-cotton. 

Among  the  numerous  kinds  of  smokeless  powder  should  be  mentioned 
the  following:  Nobel's  nitroleum  (artillery  powder)  which  consists  of  one- 
half  of  nitroglycerine  and  one-half  of  collodion  cotton.  "Poudre  B"  named 
after  General  Boulanger  and  used  in  the  French  Army.  The  "Russian," 
"Spanish"  and  "American"  powder.  In  this  country  according  to  Schiip- 
phaus  cited  by  MarshalP^  a  pyro-coUodion  powder  has  been  adopted  for  all 
kinds  of  guns.  The  composition  varies  but  averages  80  per  cent,  of  gun 
cotton,  between  10  to  ig.spercent.  of  soluble  nitrocellulose,  0.5  to  i  per  cent,  of 
urea;  some  powders  also  contain  9  per  cent,  of  nitroglycerine.  Other  varieties 
of  smokeless  powder  are  Ballistite,  a  mixture  of  40  to  50  per  cent,  of  collodion 
cotton,  and  50  to  60  per  cent,  of  nitroglycerine,  invented  by  Nobel  in  1887. 

In  order  to  make  the  powder  more  stable  or  to  improve  its  physical  prop- 
erties it  is  mixed  with  such  substances  as  diphenylamine,  aniline  and  calcium 
carbonate. 

Filite  is  the  Italian  name  for  ballistite  because  it  is  drawn  out  into  cords 
instead  of  flakes.  It  consists  of  equal  parts  of  nitroglycerine  and  collodion 
cotton  with  0.5  to  i  per  cent,  of  aniline.  Tonite  is  a  mixture  of  gun  cotton  and 
nitrate  of  barium  in  almost  equal  proportions.  Solenite,  also  used  as  a  mili- 
tary powder  in  Italy,  is  composed  of  33  per  cent,  of  nitroglycerine,  i  to  3  per 
cent,  of  light  colored  mineral  jelly  and  the  rest  of  nitrocellulose.  The  mix- 
ture is  gelatinized  with  acetone  and  the  dough  is  pressed  into  a  tubular  form 
and  cut  into  short  lengths.  The  grains  are  translucent  and  resemble  light 
brown  glass  beads. 

The  Germans  employ  a  variety  of  smokeless  powder.  The  "  Wiirfelpulver" 
is  similar  in  composition  to  the  Italian  Filite,  but  is  made  up  in  the  form  of 
cubes  instead  of  tubes.  Cordite  is  essentially  a  British  invention  and  is  now 
considered  one  of  the  most  successful  smokeless  powders.  The  composition 
of  the  modified  form  is  gun  cotton  65  per  cent.;  nitroglycerine  30  per  cent, 
and  vaseHne  5  per  cent.  Marshall  credits  Col.  Sir  F.  L.  Nathan  of  the  British 
Army  with  marked  improvements  in  the  manufacture  of  cordite  as  regards 
safety  of  the  workmen,  stability  of  the  explosive  and  reduced  cost  of  the 
product. 

Professor  Munroe  reports  that  a  notable  change  in  practice  in  the  manu- 
facture of  smokeless  powder  in  the  United  States  has  been  the  abandonment 
of  the  nitroglycerine — nitrocellulose  powder  by  the  Army,  and  the  adoption 
of  a  straight  nitrocellulose  powder  of  definite  nitrogen  contents  as  used  in 


558        ETIOLOGY   AND    PROPHYL.\XIS    OF    OCCUPATIONAL   DISEASES 

the  Navy.  The  tendency  in  military  powder  is  to  approach  more  closely 
the  principle  set  forth  by  Munroe  many  years  ago  as  governing  the  ideal 
smokeless  powder,  viz.,  that  "it  should  be  composed  of  a  single  chemical 
substance  in  a  state  of  chemical  purity." 

The  smokeless  shot  gunpowders  are  manufactured  in  great  variety,  in 
diflFerent  countries  and  are  broadly  divided  into  the  "condensed"  and  "bulk 
types."  In  the  former  the  gun  cotton  is  completely  gelatinized  and  the 
process  of  manufacture  is  similar  to  that  of  rifle  powder,  except  that  the  paste 
is  formed  into  small  grains  or  thin  flakes. 

In  the  production  of  bulk  powder  other  ingredients  such  as  paraffine 
wax,  starch,  lamp  black,  wood  meal,  various  gums,  potassium  ferricyanide, 
nitrates  of  barium  and  potassium,  bichromates  of  potassium  and  ammonia 
and  the  mono  and  dinitro  derivatives  of  benzene  and  toluene  are  used  in 
some  of  the  powders. 

For  a  very  complete  account  of  the  production  of  smokeless  shot  gun- 
powder by  Professor  Munroe.  (See  U.  S.  Census  Bulletin  No.  92,  1908, 
page  84,  and  Marshall's  book  on  Explosives.) 

Nitroglycerine  was  discovered  by  Sobrero  in  1847  and  is  made  by  the 
action  of  a  mixture  of  nitric  and  sulphuric  acids  on  anhydrous  glycerine. 

Professor  Munroe"^  states  that  "by  the  use  of  artificial  refrigeration  the 
yield  of  nitroglycerine  from  a  given  mass  of  acid  is  increased,  the  speed  of 
nitration  is  likewise  increased,  the  danger  attending  nitration  is  decreased 
and  the  use  of  a  second  separator  is  rendered  unnecessary."  The  first  at- 
tempts to  use  nitroglycerine  in  a  liquid  form  for  blasting  purposes  proved  so 
disastrous  that  a  number  of  countries  prohibited  its  use.  Alfred  Nobel  in 
1866  discovered  that  when  mixed  with  "Kieselguhr"  (an  infusorial  earth) 
previously  heated  to  redness,  it  could  be  rendered  less  sensitive  and  more 
safely  handled  and  transported.  This  product  is  now  known  as  dynamite. 
Nobel  further  discovered  in  1875  that  by  the  substitution  of  gun  cotton  for 
Kieselguhr  in  the  proportion  of  7  or  8  per  cent,  of  the  gun  cotton  to  92  or 
93  per  cent,  of  nitroglycerine,  the  latter  was  converted  into  a  gelatinous  solid, 
which  he  called  "  blasting  gelatine."  This  blasting  gelatine  forms  the  basis  of 
numerous  valuable  high  explosives.  Other  explosives  referred  to  by  A. 
Cooper  Key^^  are  Gelatine  dynamite,  which  is  composed  of  nitroglycerine 
thickened  by  the  addition  of  gun  cotton  and  combined  with  wood  meal, 
charcoal  or  certain  other  non-explosive  ingredients.  "Gelignite  a  very 
widely  used  high  explosive  is  practically  gelatine  dynamite  with  the  addition 
of  saltpeter.  Carbonite  is  composed  of  about  27  per  cent,  of  nitroglycerine 
absorbed  in  a  dope  of  woodmeal  and  nitrate  of  potassium  or  barium." 
In  America,  according  to  Marshall,  the  formulae  vary  considerably,  and  am- 
monia dynamites  are  made  in  which  a  large  proportion  of  the  nitroglycerine 
is  replaced  by  ammonium  nitrate. 

Nitroglycerine  can  be  readily  detonated  by  friction  or  fulminate  percus- 
sion caps.     It  is  known  to  be  a  strong  poison  which  may  be  inhaled  and  can 


EXPOSURE  TO  OCCUPATIONAL  INTOXICATIONS  559 

also  be  absorbed  by  the  skin  and  from  the  alimentary  canal.  (For  effects 
see  list  of  Industrial  Poisons,  page  733.) 

Key^^  states  that  "no  one  can  enter  a  cordite  drying  room  without  ex- 
periencing a  peculiar  sensation  at  the  heart  and  at  the  back  of  the  head,  which 
in  the  absence  of  fresh  air  soon  develops  into  a  headache  which  reduces  to 
insignificance  all  the  other  ills  of  life."  So  far  as  he  could  gather  no  perma- 
nent harm  resulted  from  this  cause,  and  on  most  people  the  fumes  appear 
to  lose  their  effect  after  a  few  days,  in  others  it  takes  weeks  before  they  be- 
come inured  and  in  still  others  a  return  to  the  work  after  a  few  days  absence 
causes  the  original  symptoms.  Rambousek^^  cites  Robert's  case,  where 
the  rubbing  of  a  single  drop  of  nitroglycerine  into  the  skin  caused  symp- 
toms lasting  10  hours. 

While  Oliver^ ^  states  that  women  who  mix  Kieselguhr  and  nitroglycerine 
do  not  suffer,  Rambousek^*  reports  that  workmen  engaged  in  washing  out 
nitroglycerine  from  Kieselguhr  earth,  having,  in  doing  so,  their  bare  arms 
immersed  in  the  liquid,  suffered.  Other  injurious  effects  especially  noted 
in  the  mixing  and  sifting  of  dynamite  are  obstinate  ulcers  under  the  nails 
and  finger  tips  and  eruptions  on  interdigital  spaces  and  the  plantar  aspect  of 
the  feet.  There  is  also  considerable  danger  from  nitrous  fumes  unless  the 
nitration  is  carried  on  in  a  closed  apparatus.  Accidents  from  this  cause  are 
still  possible  in  the  acid  separating  house,  wash  house  and  in  the  denitration 
room  of  waste  acids.  Rambousek  reports  a  fatal  case  in  a  workman  who 
tried  to  wash  away  with  water  the  acid  which  had  overflowed  and  inhaled 
so  much  nitrous  fumes  that  he  died  16  hours  later.  Among  other  fatal  in- 
stances he  mentions  the  case  of  an  employee  in  a  dynamite  factory  who 
perished  in  cleaning  out  a  storage  tank  for  waste  acid,  in  spite  of  previous 
swilling  and  ventilation. 

Dr.  C.  E.Laws^^  gives  a  very  vivid  description  of  the ''nitroglycerine  head" 
from  which  the  men  employed  in  dynamite  and  gelatine  factories,  miners  and 
excavators  so  frequently  and  severely  suffer.  He  states  that  a  man  working 
in  powder  may  cause  another  person  a  great  deal  of  misery  by  simply  shaking 
hands  or  permitting  articles  which  he  has  been  using  to  be  handled  by  the 
other.  A  worker  frequently  carries  some  of  the  drug  in  his  clothing  to  his 
home  and  may  make  his  whole  family  sick.  Sleeping  in  the  same  bed  or 
wearing  contaminated  clothing  will  produce  effects.  Apart  from  the  symp- 
toms described  in  the  list  of  industrial  poisons  page  733.  Laws  states  that 
powder  men  become  easily  intoxicated  with  a  tendency  to  develop  acute 
maniacal  attacks  and  that  all  who  work  in  it  are  sooner  or  later  troubled 
with  dyspnoea  and  tachycardia  on  exertion;  he  also  states  that  the  drug  has 
a  marked  aphrodisiac  effect*  and  that  most  glycerine  men  have  large 
families. 

Dr.  Evans^''  reports  a  case  of  nitroglycerine  poisoning  in  a  farmer.  The 
symptoms  developed  after  i  week  of  work  of  blasting  stumps  with  a  giant 
powder  of  the  nitroglycerine  variety.     Dr.  Evans  found  that  the  man  wore 


560        ETIOLOGY   AND   PROPHYLAXIS    OF   OCCUPATIONAL  DISEASES 

cotton  gloves  which  aided  by  perspiration  had  become  saturated  with  the 
powder  and  evidently  caused  the  symptoms  by  absorption. 

Dr.  Geo.  E.  Ebright^^  in  studying  the  effects  of  nitroglycerine  in  those 
engaged  in  its  manufacture  with  the  Dupont  Powder  Co.  at  Hercules,  CaU- 
f ornia,  found  only  occasionally  persons  immune  to  the  effects  of  nitroglycerine, 
and  that  there  is  a  special  susceptibiHty  in  warm  weather.  In  order  to  main- 
tain their  immunity  workers  are  in  the  habit  of  placing  some  of  the  products 
under  the  hatband,  during  periods  of  absence  from  the  factory.  The  general 
health  appeared  to  be  in  no  way  impaired,  but  this  he  attributes  largely  to 
the  picked  character  of  the  men.  He  also  refers  to  the  cordite  habit  which 
developed  in  the  British  Army  during  the  Boer  War.  The  narcotic  effects 
were  accidently  discovered.  The  habitue  is  able  to  take  the  contents  of  a 
cartridge,  his  face  flushes,  his  head  throbs  and  seems  to  swell  and  then  in 
about  15  minutes  comes  a  long  sleep.  On  awakening  he  suffers  from  intense 
headache  and  thirst.  When  mixed  with  beer  or  hot  tea  it  causes  a  wild 
delirious  intoxication  and  this  is  followed  by  sleep. 

Roburite,  Ammonite,  Securite,  Etc. — Reference  has  been  made  on  page 
544  to  dinitrobenzol,  which  is  the  combustible  ingredient  not  only  of  the  ex- 
plosives named,  but  also  of  other  high  explosives,  chiefly  in  combination  with 
ammoniima  nitrate.  There  are  a  large  number  of  explosives  which  contain 
more  or  less  of  dinitro-compounds  mixed  with  a  chlorinated  hydrocarbon. 
While  dinitrobenzol  was  formerly  most  commonly  employed,  trinitrotoluene 
is  now  most  extensively  used,  alone  or  combined  with  nitrate  of  ammonium, 
potassium  or  barium  as  oxidizing  agents. 

According  to  Rambousek  ammonite  is  a  mixture  of  nitro-naphthalene  and 
ammonium  nitrate;  securite  is  the  same  as  roburite  with  the  addition  also 
of  ammonium  oxalate. 

A  number  of  cases  of  poisoning  in  the  manufacture  of  roburite  are  cited 
by  Rambousek^*  and  also  the  fact  that  in  the  Witten  factory  almost  all  the 
workers  between  1890-7  suffered  from  pallor,  blue  lips  and  yellowish  con- 
junctiva. The  morbidity  has,  however,  been  materially  decreased  by  effi- 
cient preventive  measures.  Cases  of  poisoning  have  also  been  reported  in 
the  nitrotoluene  department  of  explosive  plants  due  to  nitrous  fumes  and 
mono-nitrotoluene. 

The  process  of  grinding,  melting,  cooUng,  mixing  and  fitting  in  air-tight 
cartridges  is  generally  well  safeguarded;  the  chief  danger  is  from  dinitro- 
benzol and  toluene.    (For  symptoms  and  effects,  see  list  of  Industrial  Poisons.) 

Explosions  are  liable  to  occur  in  Benzol  plants  as  shown  by  the  accident 
reported  in  Birmingham,  Alabama,  October  16,  1915. 

Picric  acid  formerly  used  in  the  manufacture  of  melinite  and  lyddite  is 
being  replaced  to  a  considerable  extent  with  trinitrotoluene.  Cases  of  poison- 
ing from  picric  acid  are  rare,  although  skin  affections,  vesicular  eruptions 
and  yellow  pigmentation  of  the  epidermis  and  of  the  conjunctiva  and  diges- 
tive derangements  have  been  attributed  to  this  agent. 


EXPOSURE  TO  OCCUPATIONAL  INTOXICATIONS  56 1 

Safety  Explosives. — There  is  no  such  a  thing  as  a  safety  explosive.  The 
term  should  be  limited,  first  to  those  explosives  which  are  comparatively 
insensitive  to  blows  and  friction,  such  as  ammonium  nitrate  explosives  con- 
taining no  nitroglycerine  and  hence  are  safe  in  handling,  and  second  to  those 
explosives  that  have  been  officially  tested  and  found  to  be  comparatively 
safe  for  explosion  in  the  presence  of  fire  damp  and  coal  dust.  In  numerous 
countries  so-called  permissible  explosives  are  listed  and  explosives  which 
do  not  come  up  to  the  required  standard  cannot  be  used  in  coal  mines. 
(For  classification  and  lists  of  permissible  explosives  see  Marshall's 
book,  1915,  page  472,  and  Bulletin  No.  17,  U.  S.  Bureau  of  Mines,  1911, 
page  26.) 

In  1875  Great  Britain  passed  a  law  for  the  prevention  of  accidents  in  the 
explosive  industry,  which  provided  for  the  appointment  of  inspectors  with 
power  to  inspect  all  magazines  and  factories  and  see  that  the  operations  are 
carried  on  in  a  reasonably  safe  manner.  As  a  result  the  fatalities  from  ex- 
plosions have  been  reduced,  according  to  Marshall,  from  an  average  of  43 
killed  per  annum  in  1870  to  seven  in  1 913,  in  spite  of  a  great  increase  in  the 
number  of  employees. 

The  Choice  of  a  High  Explosive. — ^Marshall*^"  in  discussing  this  subject 
states  that  for  blasting  very  hard  rock,  such  as  gold  quartz,  blasting  gelatine 
gives  the  best  results,  provided  it  be  fired  with  a  very  powerful  detonator  or 
primer  of  non-gelatinized  nitroglycerine  f^xplosive,  such  as  American  straight 
dynamite  or  lignin. 

For  soft-rock  blasting,  gelignite  is  most  commonly  used  in  Great  Britain; 
ammonium  nitrate  and  chlorate  explosives  are  also  employed.  For  coal- 
mining operations  Robbinite  is  most  popular.  For  agricultural  purposes, 
such  as  breaking  up  hard  subsoil,  removal  of  tree  stumps,  digging  ditches, 
etc.,  if  the  charge  can  be  tamped  well,  blasting  powder  will  answer.  If  not, 
a  detonating  explosive  should  be  used.  For  blasting  rock  under  water  a 
brisant  explosive  is  required  and  the  cartridge  should  be  thoroughly  water- 
proofed, unless  the  explosive  contains  a  considerable  percentage  of  gelatinized 
nitroglycerine. 

For  military  blasting  operations,  gun  cotton  compressed  in  powerful 
hydraulic  presses,  also  picric  acid  powder,  trinitrotoluene,  and  other  nitro- 
derivative  explosive  compounds  are  most  commonly  employed.  Smokeless 
powder  and  the  ordinary  commercial  explosives  are  also  used  by  military 
engineers. 

For  submarine  mines  and  torpedo  war  heads  the  requirements  are  much 
the  same  as  for  military  blasting  explosives.  Nobel  is  said  to  have  used 
mines  of  nitroglycerine  to  protect  the  mouth  of  the  Neva  during  the  Crimean 
War.  Picric  acid  has  been  used,  but  this  has  been  to  a  great  extent  replaced  by 
trinitrotoluene.  During  the  American  Civil  War  torpedoes  containing  about 
60  lb.  of  gunpowder  were  employed  in  the  defense  of  river  sand  harbors.  On 
June  4,  1864,  according  to  the  surgical  history  of  the  war,  two  large  torpedoes 
36 


562        ETIOLOGY   AND   PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

were  accidentally  exploded  near  New  Berne,  killing  36  soldiers  and  8  negroes 
and  seriously  wounding  29  men. 

Foiigasses  are  small  subterraneous  mines  constructed  in  front  of  the  weak 
parts  of  a  fortification.  Dunng  the  American  Civil  War  they  were  also 
placed  along  the  roads  leading  to  important  points.  They  are  as  a  rule 
simply  large  shells  arranged  with  levers  connected  with  a  percussion  cap  and 
sunk  below  the  surface  of  the  ground  in  the  supposed  path  of  the  assailing 
party.  A  pressure  of  the  foot  upon  the  concealed  lever  is  sufi&cient  to  explode 
the  shell.     In  modern  times  they  are  exploded  by  means  of  electrical  current. 

For  shells,  which  are  hollow  iron  or  steel  projectiles  adapted  for  enclosing 
a  quantity  of  gunpowder  or  other  explosive  compounds  and  designed  to  be 
torn  asunder  upon  the  explosion  of  this  material,  the  ordinary  black  powder 
was  used  almost  exclusively  for  a  long  time.  After  the  discovery  of  gun  cot- 
ton, picric  acid  and  other  high  explosives  they  were  given  a  trial,  and  at  the 
present  time  trinitrotoluene  compounds  are  most  commonly  used. 

A  shrapnel  is  a  shell  filled  with  musket  balls  consolidated  into  a  mass  by 
a  composition  of  sulphur,  or  the  balls  are  imbedded  in  melted  trinitrotoluene. 
The  shells  are  exploded  by  a  charge  of  powder  fitted  into  their  interior  which 
may  be  ignited  either  by  a  time  or  percussion  fuse. 

Armor  piercing  shells  are  expected  to  pass  through  the  armor  and  explode 
when  they  are  on  the  other  side.  Many  of  the  mechanical  difficulties  for 
the  attainment  of  this  object  have  been  overcome.  Black  powder  is  still 
extensively  used  to  fill  these  shells,  as  the  nitro-aromatic  explosives  generally 
detonate  on  the  face  of  the  armor  plate.  Ammonium  nitrate  explosives  like 
ammonal  also  satisfy  the  requirements,  except  that  they  are  very  deliques- 
cent, which  renders  their  storage  for  long  periods  difficult. 

Hand  grenades  are  small  iron  shells  from  2  to  3  in.  in  diameter  filled  with 
powder  and  discharged  by  percussion.  They  were  first  introduced  in  the 
seventeenth  century,  lost  for  a  time  their  importance  but  were  used  not  only  in 
our  Civil  War,  but  appear  also  to  be  extensively  employed  in  the  present  Euro- 
pean War"  in  sieges  and  assaults  at  close  quarters.  Their  efi'ects  are  similar 
to  ordinary  shells.  At  present  the  explosives  most  used  are  picric  acid, 
trinitrotoluene,  compressed  gun  cotton,  tonite  and  smokeless  powder.  The 
bombs  thrown  from  flying  machines  during  the  present  European  War  are 
doubtless  of  a  similar  nature. 

Liquid  and  Gaseous  Projectiles.— During  the  present  war  some  pro- 
jectiles of  a  liquid  and  gaseous  nature  appear  to  have  been  revived  and  possi- 
bly new  ones  invented.  Among  those  may  be  the  "carcass,"  which  is  a 
spherical  shell  having  three  additional  holes  of  the  same  dimensions  as  the 
fuse  hole,  and  filled  with  a  composition  which  burns  with  intense  power  from 
8  to  10  minutes  and  the  flames  issuing  from  the  holes  set  fire  to  everything 
combustible  within  reach.  It  was  chiefly  used  for  incendiary  purposes  and 
to  light  up  positions  at  night.  The  so-called  "Greek  Fire,"  composed  of  a 
mixture  of  coal  tar,  naphtha,  turpentine  or  coal-oil  mixed  with  phosphorus, 


EXPOSURE  TO  OCCUPATIONAL  INTOXICATIONS  563 

according  to  the  surgical  historian  of  the  Civil  War  was  employed  at  the 
siege  of  Charleston  in  1863,  but  its  obvious  barbarity  led  to  its  speedy  dis- 
continuance. The  employment  of  the  suffocating  gases  like  chlorine  and 
bromine  has  been  reported  in  the  present  war.  Among  the  liquid  projec- 
tiles may  be  mentioned  the  water  shell  invented  by  Prof.  Abel  of  Woolwich, 
The  missile  consists  of  ordinary  shells  filled  with  water  and  fixed  with  com- 
pressed gun  cotton  and  a  detonator  of  fulminate  of  mercury. 

Manufacture  of  Small  Arm  Ammunition. — We  have  no  detailed  statistics 
relative  to  the  risks  attending  this  occupation,  except  Key's  table/^  which 
indicates  that  of  the  175  accidents  which  occurred  in  the  decade  from  1890-99 
in  Great  Britain  in  the  explosive  industry,  39  occurred  in  the  manufacture 
of  ammunition,  with  5  deaths  and  43  injured.  Apart  from  this  danger,  the 
workmen  are  also  exposed  to  industrial  poisons  and  the  hazard  incident  to 
brass  founding,  metal  working,  machine  shopping,  soldering,  wood  working, 
painting  and  varnishing.  (See  p.  570)-  The  following  is  a  summary  of 
conditions  observed  by  Hayhurst®^  in  his  Ohio  Survey: 

The  waterproofing  of  paper  shells  by  means  of  hot  paraffine  was  a  hot 
and  steamy  process.  The  manufacture  of  felt  and  wads  for  these  cartridges 
was  also  hot  and  steamy  and  attended  with  a  peculiar  foul  odor  due  to  the 
dirty  cow  hair.  The  work  in  the  lead  room  and  loading  and  packing  of  the 
shells  was  practically  all  mechanical  and  appeared  to  be  free  from  occupa- 
tional hazards.  The  manufacture  of  copper  and  brass  shells,  especially  the 
annealing  and  washing  process,  was  characterized  as  hot,  wet  and  humid. 
The  loading  and  packing  of  rifle  cartridges  was  a  mechanical  process,  girls 
operating  the  machines,  and  did  not  touch  the  lead.  In  the  manufacture  of 
fulminate  priming  caps  the  man  who  did  the  work  was  thoroughly  skilled 
and  realized  the  danger  both  as  to  explosion  and  as  to  poisoning  from  fulmi- 
nate of  mercury.  In  the  nitroglycerine  department  the  work  was  also  done 
by  skilled  men,  but  some  of  the  helpers,  it  was  said,  occasionally  complained 
of  headache,  flushing  of  the  face  and  a  feeling  of  distention  in  the  stomach. 

Fuses. — A  great  many  varieties  of  fuses  for  the  ignition  of  the  detonator 
or  for  the  direct  ignition  of  a  blasting  charge  have  been  designed.  Marshall 
and  other  authors  describe  in  detail  the  manufacture  of  safety  fuses,  miner's 
squibbs,  quills,  quick  match,  instantaneous  fuse,  slow  match,  detonating 
fuses,  electric  fuses,  mechanical  fuses  and  shell  fuses.  The  latter  are  made 
in  two  main  varieties,  viz.,  percussion  and  time  fuses.  The  work  is  generally 
carried  on  with  great  precaution,  as  regards  cleanliness,  clothing  and  safety 
measures. 

Hayhurst  in  discussing  the  manufacture  of  electric  fuses  refers  to  noise 
as  a  factor  in  the  spinning  process  of  white  cotton  upon  the  copper  wire  to  be 
used  for  insulation.  He  refers  to  the  tarring  of  covered  wire  as  hot  and  humid 
work,  but  considered  the  hazards  in  the  bridging  room,  where  the  soldering 
of  platinum  wire  across  points  and  running  sulphur  into  moulds  around  the 
points  was  done  by  girls,  as  quite  negligible. 


564        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL  DISEASES 

Fireworks. — Most  of  the  mixtures  used  for  rockets  are  practically  iden- 
tical with  those  used  as  explosives,  such  as  mealed  powder,  combined  with 
slow  burning  substances.  Among  the  different  rockets  described  by  Mar- 
shall are  those  used  for  pyrotechnique  displays,  the  war  rocket,  employed  for 
incendiary  purposes  and  attacks  of  air  ships.  Sound  and  hght  rockets,  the 
latter  are  employed  as  a  flash  Ught  to  light  up  positions.  Life  saving  rockets 
are  used  by  the  Coast  Life  Saving  Service  and  others  for  throwing  life  Hnes. 
Fireworks  also  include  the  various  colored  Hghts,  such  as  green,  yellow,  blue, 
and  red  lights.  Many  of  the  ingredients  such  as  phosphorus,  sulphites  of 
arsenic,  antimony  and  copper  are  industrial  poisons,  but  their  chief  danger 
lies  in  accidents  from  explosions.  Marshall  ^^  refers  to  24  accidents  from 
1910-1913  causing  25  deaths  and  injuries  to  64  persons. 

Accidents  in  the  Manufacture  and  Use  of  Explosives. — ^Considering  the 
vast  quantities  of  explosives  manufactured,  the  number  of  accidents  is  sur- 
prisingly small.  According  to  Key^*  during  the  year  1899  the  total  quantity 
of  gunpowder,  other  nitrate  mixtures,  nitro-compounds  and  chlorate  mix- 
tures manufactured  in  the  United  Kingdom  exclusive  of  Government  fac- 
tories was  32,115  tons.  There  was  also  produced  about  500,000,000  cartridges 
for  small  arms,  50,000,000  detonators,  electric  detonators  and  fuses  and  about 
the  same  number  of  yards  of  safety  fuses.  In  addition  there  were  manu- 
factured about  1788  tons  of  fire  works  while  the  output  of  fulminate  of  mer- 
cury could  not  be  disclosed. 

According  to  Munroe^^  the  output  of  gunpowder  in  the  United  States  in 
1900  amounted  to  10,383,944  lb.,  blasting  powder  kegs  of  25  lb.  each.  8,217,- 
448  kegs;  smokeless  powder  7,009,720  lb.;  nitroglycerine  51,579,270  lb.; 
dynamite  130,920,829  lb.;  gun  cotton  5,905,958  lb.  The  total  output  of 
explosives  in  the  United  States  in  1905  was  363,748,097  lb.,  and  in  1910  the 
output  was  estimated  at  nearly  500,000,000  lb. 

During  the  decade  from  1890  to  1899,  175  accidents  occurred  in  the  manu- 
facture of  explosives  in  Great  Britain,  resulting  in  the  death  of  44  persons 
and  injuries  to  204  out  of  a  total  of  4828  persons  employed  in  the  danger 
buildings,  and  11,098  persons  exposed  in  licensed  area.  This  favorable 
showing  is  largely  due  to  the  intelligence  and  care  taken  by  the  employees  and 
employers  and  general  safety  precautions.  Among  the  specially  dangerous 
processes  Key^^  enumerates  the  "milling"  or  "incorporation"  of  gunpowder, 
"the  pressing  of  detonators  and  the  mixing  of  cap  composition." 

In  addition  to  the  above  accidents  in  actual  manufacture  69  accidents 
with  32  deaths  and  81  injuries  occurred  during  the  storage  and  distribution 
of  the  finished  product.  Among  the  principal  preventive  measures  Key 
mentions  the  following:  "  (a)  subdivision  of  risks,  i.e.,  the  number  of  persons 
allowed  in  any  one  'danger'  building  is  strictly  limited  and  the  communica- 
tion of  explosion  between  buildings  is  prevented  by  the  erection  of  mounds 
of  earth  or  masonry  and  by  making  the  quantity  of  explosive  in  any  building 
directly  dependent  on  its  distance  from  others;  {b)  scrupulous  attention  to 


EXPOSURE    TO    OCCUPATIONAL   INTOXICATIONS  565 

cleanliness;  (c)  prevention  of  the  introduction  of  matches  and  other 
dangerous  articles,  by  providing  suitable  clothing  without  pockets  and  by 
a  thorough  system  of  searching  all  those  employed  in  danger  buildings;  and 
(d)  the  provision  of  an  adequate  number  of  escape  doors  opening  outward, 
and  provided  with  safety  latches  so  as  to  yield  easily  to  a  push  from  the 
inside." 

It  is  the  concensus  of  opinion,  that  the  explosive  industry  with  care  and 
proper  safeguard  is  not  an  extraordinary  dangerous  trade,  and  that  the  risk 
in  the  use  of  explosives  is  greater  than  in  its  manufacture.  This  is  illustrated 
in  Key's  table,  showing  the  number  of  accidents  in  the  handling  and  use  of 
various  explosives  during  the  decade  of  1890-99. 


Nature  of  explosive  aSenta 


No.  of  persons 


KiUed 


Injured 


1.  Gunpowder* j  244  94 

2.  Nitroglycerine  compounds 376  135 

3.  Ammonium  nitrates j  44  12 

4.  Detonators 143  3 

5.  Fireworks 41  19 


Total '         848 

Total  in  manufacture  during  same  period I  175 


263 
44 


294 
440 

41 
193 

96 


1064 
204 


According  to  Key  the  majority  of  these  accidents  99  out  of  100  could  have 
been  avoided  by  reasonable  care.  Among  the  immediate  causes  of  explo- 
sions in  mines  in  Great  Britain  in  1899  which  killed  29  and  injured  195  were 
scraping  out  the  detonators  with  pins,  thawing  dynamite  over  the  fire,  driving 
dynamite  and  gunpowder  by  means  of  iron  rods  into  roughly  drilled  holes, 
and  boring  out  of  misfires.  Key  cites  a  fatal  accident  which  was  reported 
as  follows:  A.  B.  was  charging  a  bore  hole  in  rock  with  pellet  gunpowder. 
Finding  a  difficulty  in  inserting  the  charge  he  was  holding  the  tamping  rod 
on  the  powder  while  his  mate  drove  it  home  with  a  sledge  hammer  when 
for  no  reason  whatever  the  charge  exploded.     The  italics  are  Key's. 

It  is  very  evident  from  the  examples  of  reckless  folly  cited  by  Key  that 
much  needs  to  be  done  in  the  way  of  instruction  and  discipHne  to  diminish 
this  needless  sacrifice  of  life  and  limbs. 

During  the  year  1913  over  130  men  were  killed  and  250  seriously  injured 
by  the  use  of  explosives  in  the  metal  mines  and  quarries  in  the  United  States 
alone.  The  statistics  of  the  railway  bureau  for  the  safe  transportation  of 
explosives,  cited  in  191 1  by  Professor  Holmes  in  Bulletin  17  Bureau  of  Mines, 

*  In  the  year  1899  alone  146  accidents  with  gunpowder  in  mines  killed  15  persons  and 
injured  148.  Few  if  any  of  these  were  reported,  and  if  multiplied  by  10  and  added  to  the 
casualties  due  to  this  explosive,  the  figures  under  heading  i  would  be  enormously  increased. 


566         ETIOLOGY    AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

have  shown  more  than  400  persons  were  killed  or  injured  and  over  $3,000,000 
worth  of  property  destroyed  by  explosions  in  transit  by  rail. 

The  losses  from  the  latter  accidents  in  transport  have  been  reduced  to 
almost  nothing,  and  Prof.  Holmes  declares  that  the  "  accidents  resulting  from 
the  improper  use  of  explosives  in  mining  can  be  most  certainly  prevented  (i) 
through  the  use  of  the  best  and  safest  explosives,  (2)  through  the  handling 
and  firing  of  these  explosives  in  the  safest  manner  by  carefully  selected  and 
trained  men,  and  (3)  through  the  strict  and  competent  oversight  of  these 
men." 

Dangers  from  the  Products  of  Combustion. — Apart  from  the  accidents 
referred  to  it  should  be  remembered  that  the  gaseous  products  of  combustion 
in  confined  spaces,  such  as  mines  and  tunnels  may  prove  a  very  serious  danger 
to  the  operatives. 

The  gaseous  products  in  the  explosion  of  various  gunpowders  averages 
as  follows:  Carbon  dioxide  49.3;  carbon  monoxide  12.5;  hydrogen  2.2; 
methane  0.4;  nitrogen  32.9;  sulphureted  hydrogen  2.6  volume  per  cent. 
Whenever  an  explosive  is  used  in  which  the  oxidizing  agents  are  insufficient 
to  convert  all  the  carbon  into  dioxide,  and  the  hydrogen  into  water,  the 
amount  of  monoxide  evolved  may  be  greatly  increased.  The  gas  from  black 
powder  contains  between  8  and  17  per  cent,  of  carbon  monoxide  and  many 
of  the  explosives  used  in  mines  give  off  more  carbon  monoxide  than  dioxide. 
MarshalP^  refers  to  several  fatalities  from  this  cause  in  Germany  in  1904  and 
1908  and  it  is  generally  believed  that  the  undue  prevalence  of  respiratory 
diseases  in  the  South  African  gold  mines  and  elsewhere  is  influenced  by  the 
presence  of  monoxide  of  carbon  in  these  mines.  He  also  states  that  the  high 
explosives  used  for  military  purposes  such  as  gun  cotton,  picric  acid  and  tri- 
nitrotoluene evolve  large  quantities  of  carbon  monoxide  when  detonated 
and  hence  are  unsuitable  for  underground  operations.  Sulphureted  hydro- 
gen is  freely  given  off  by  American  dynamite.  Blown  out  shots  are  liable  to 
produce  other  poisonous  gases  and  vapors  such  as  acrolein  and  prussic  acid. 
When  nitroglycerine  is  decomposed  by  simple  combustion  instead  of  detona- 
tion apart  from  CO  and  CO2  the  highly  poisonous  nitrous  fumes  are  given  off. 
j^gy66  j-efers  to  a  number  of  instances  of  poisoning  from  one,  or  a  combination 
of  these  gases.  Nitroglycerine  explosives  according  to  Jakoby  and  His,  cited 
by  Marshall,"  distil  off  part  of  this  cofistituent  which  condenses  again  to  a 
fine  mist  in  the  air.  If  a  sweet  taste  be  observed  in  the  air  the  miners  should 
leave  at  once  and  not  return  until  it  has  disappeared.  Dr.  Pirrie*^  has  re- 
corded his  observations  on  unsuspected  dangers  to  the  health  of  miners  from 
the  use  of  high  explosives  containing  nitroglycerine. 

Oliver"^'-*  states  that  the  inhalation  of  the  fumes  given  off  by  high  explosives 
may  cause  violent  headache,  vomiting,  palpitation  of  the  heart  and  partial 
or  complete  collapse.  Removal  to  the  fresh  air,  warm  drinks  and  external 
artificial  heat  are  the  most  effective  remedies.  He  also  mentions  the  fact 
that  "many  of  the  miners  after  the  'gassing'  suffer  from  extreme  nervous- 


EXPOSURE  TO  OCCUPATIONAL  INTOXICATIONS 


567 


ness  and  of  a  sense  of  dread  attended  by  a  want  of  confidence  in  themselves." 
For  symptoms  caused  by  carbon  monoxide,  carbon  dioxide  and  nitrous 
fumes.     (See  list  of  Industrial  Poisons,  pages  725,  726,  734.) 

EXPLOSIVE  HAZARDS  IN  MANUFACTURING  PLANTS,  ETC.* 


Chemicals,   acids   and   acid 

vapors : 
Gases: 

Dust  explosions: 

Explosive  substances: 


Liquids  which  may  cause  ex- 
plosions under  right  con- 
ditions : 


Liquified  gases: 


Hydrochloric  acid,  hydrofluoric  acid,  nitric  and  sulphuric 
acid. 

Benzene,   gasoline,   naphtha,   acetylene,   blaugas,  gasoline 
and  pintsch  gas  lighting  sj'stems. 

Celluloid,  coal,  cork,  dextrin,  flour,  grains,  lampblack,  malt, 
sugar,  sulphur,  tow,  tobacco,  wood  dust. 
Celluloid  will  explode  from  percussion  and  the  dust  from 
celluloid  will  explode  from  a  very  small  spark  of  any  kind. 
Chlorates  are  explosive  from  slight  friction,  shocks  or  when 
crushed. 

Collodion  is  explosive  from  heat  or  shock. 
Dynamite  is  explosive  from  heat  or  shock. 
Gun  cotton  is  explosive  when  suddenly  warmed  or  from  pres- 
sure, shock  or  friction. 

Gunpowder  is  explosive  from  shock,  pressure,  friction  or  heat. 
Nitrogen  chloride  ^ill  explode  under  slightest  provocation, 
sunlight  or  violet  sound  waves. 
Nitroglycerine  is  explosive  from  heat  or  shock. 
Picrates  are  explosive  from  heat,  friction,  shock. 


Acetone 

^\lcohol 

Benzol 

Carbon  disulphide 

Ether 

Air 

Acetylene  liquid 

Ammonia 

Carbonic  acid 


Illuminating  oils 

Lacquers 

Petroleum 

Spirits 

Varnishes. 

Hydrogen 

Hydrogen  sulphide 

Oxygen 

Sulphurous  acid. 


INDUSTRIES  m  WHICH  EXPLOSIVE  HAZARDS  ARE  PRESENT 


Bleach,  dye,  print  and  finish- 
ing departments  of  textile 
mills: 


Bleaching  chemicals:  sodium  peroxide  gives  off  oxygen  and 
in  contact  with  resin,  ethereal  oils,  or  mineral  oils,  or  in  a 
room  containing  inflammable  gases  or  vapors,  may  easily 
cause  a  fire,  or  under  right  conditions,  an  explosion.  Chlor- 
ates employed  for  oxidization  purposes  especially  where 
aniline  black  dying  is  done  are  liable  to  liberate  oxygen  ex- 
plosively if  mixed  with  potassium  cyanide  or  sulphur,  or 
under  the  influence  of  friction,  shock,  concussion  or  heat. 
Explosions  from  dust  are  liable  to  occur  in  the  cleaning 
and  separating  room,  also  in  malt  grinding  mills,  from  a 
foreign  body  such  as  a  nail,  etc.,  in  the  grain,  striking  a 
spark  on  the  metallic  part  of  the  machine. 

*  Condensed  from  "Explosive  Hazards  in  Manufacturing  Plants"  by  J.  Corbit  Barden, 
Associate  Director  Bureau  of  Inspection  and  Accident  Prevention.  Published  by  the 
.\etna  Life  Insurance  Company,  Hartford,  Conn.,  1914. 


Breweries: 


568        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL  DISEASES 


Candy  factories: 


Clothing  factories : 

Cotton  mills: 
Cotton  seed  oil  mills: 


Cordage  and  twine  works: 
Fertilizer  works: 


Flour  and  cereal  mills : 

Garages: 

Glass  works: 

Glucose  and  starch  works: 


Grain    elevators    and   grain 
threshing: 

Metal  workers: 

Motion  picture  films: 

Oil  cloth  and  linoleum  plants: 

Packing  houses : 
Patent  leather  and  enamel 
leather  works: 

Printing,  binding,  and  litho- 
graphing: 
Pulp  mills: 
Rice  mills: 

Rubber  mills: 


Shirt,   collar,   cuff   factories 

and  steam  laundries: 
Shoe  factories: 
Straw  and  felt  hat  factories: 
Sugar  refineries: 

Tanneries : 

Tobacco  dryers: 

Wood  workers: 


Dust  in  starch  buck  and  sifting  and  drying  rooms.  Shel- 
lac and  alcohol  also  create  explosive  hazards  in  these 
establishments. 

From  benzine  cleaning  or  gasoline  gas  system  for  heating 
irons. 

Dust  and  lint,  open  lights. 

Dust  and  lint  should  not  be  allowed  to  accumulate  in  these 
rooms  and  material  should  be  passed  over  magnets  before 
going  to  linters. 

Dust  and  oily  flyings  create  explosive  hazards. 
If  cooking  is  done  in  closed  steam  kettles,  a  reducing  valve, 
safety  valve,  gauge  and  proper  drain  should  be  provided 
for  each  kettle. 

Dust  explosions  not  infrequent. 

From  gasoUne,  calcium  carbide  and  Presto-Lite  tanks. 
From  fuel  oil  heating  system. 

Dust  explosions  in  grinding  rooms  and  drying  rooms,  also 
from  sulphur  burners  and  nitric  acid  used  in  converting 
processes. 

Dust  explosions  from  hot  bearings,  open  lights,  static 
electric  sparks  or  any  other  form  of  fire.  Sulphur  and  car- 
bon bisulphide  and  other  volatile  and  inflammable  materials. 
From  fuel  oU,  acids,  japan  lacquer,  gas-heated  japan 
ovens,  dip  tanks  containing  volatile  oils. 
See  Celluloid. 

Dust  in  the  cork   grinding  room,  linseed-oil   boiling,  com- 
pound mixing,  explosive  vapors. 
Fires  spread  rapidly  on  account  of  grease  and  oil. 
Daubs,   japan,  varnish,  oils,  lampblack,   naphtha.     Direct 
heat  and  open  flames  of  any  kind  should  never  be  used  or 
allowed  where  coating  or  mixing  is  done. 
From  gasoline  gas  or  linotype  machines,  benzine  used  for 
type  cleaning,  collodion  in  photo-department. 
Sulphur  and  sulphur  burners,  digesters. 
Same  as  flour  mills,  sparks  are  especially  dangerous  at  the 
attrition  machines. 

From  lampblack  and  oxides  used  for  compounding.     From 
naphtha  especially  in  the  churn  room,  and  in  the  spreading 
machines,  the  latter  should  be  properly  grounded  to  prevent 
static  sparks. 
From  gasoline  gas  system  and  for  heating  irons. 

From  rubber  cement  and  waterproofing  material. 

From  gasoline  gas  system,  also  sulphur  and  sodium  peroxide. 

Danger    from    dust     explosion.     Vacuum    boiling    kettles 

should  be  provided  with  proper  safety  valves  and  gauges. 

Dust  hazards  in  bark  mill  rooms.     Naphtha  indegreasing 

processes. 

Dust  explosion  risk  is  due  to  the  greasy  and  inflammable 

character  of  tobacco  dust. 

Dust     explosion    hazards    in    sandpapering    rooms,    also 

varnish  dip  tanks  and  from  naphtha,  oils  and  varnishes. 


EXPOSURE   TO   OCCUIPATIONAL   INTOXICATIONS  569 

Industrial  aniline  poisoning,  which  is  just  beginning  to  be  known  in  this  country,""  has 
already  been  the  cause  of  numerous  cases  of  sickness  among  workers  in  rubber  goods;  in 
reclaiming  rubber  from  scrap,  in  making  aniline  from  benzene  and  in  using  certain  washes 
for  printing-press  rollers.  Dr.  G.  L.  Apfelbach  in  1913  reported  the  first  two  cases  of 
industrial  aniline  poisoning  in  this  country,  one  in  a  press  feeder,  and  one  in  a  dry  color 
factory.  Birge  in  1914  reported  two  cases  in  painters,  who  were  using  aniline  black  paint. 
Hayhurst  in  1915  reported  three  cases  in  men  employed  at  rubber  mixing  mills  and  among 
printing  pressmen,  who  used  a  roller- wash  rich  in  aniline.  Luce  and  Hamilton  in  their  inves- 
tigation for  the  Federal  Bureau  of  Labor  in  1915,  collected  several  cases  in  connection  with 
the  rubber  industry  at  Akron,  Ohio,  and  since  the  publication  of  the  Government  report 
have  observed  several  additional  cases.  The  present  war  has  compelled  the  manufacture 
of  aniline  oil  in  this  country,  and  in  one  establishment  at  Akron  with  a  daily  output  of 
2500  pounds,  cases  of  aniline  poisoning  are  sufliciently  common  for  workmen  and  physicians 
to  speak  of  the  victims  as  "blue  men"  or  "blue  boys." 

The  monthly  review  of  the  U.  S.  Bureau  of  Labor  Statistics  for  June,  1916,  contains 
abstracts  of  the  reports  of  the  British  committee  on  the  health  of  munition  workers.  On 
page  83  the  necessity  of  protective  measures  against  exposure  to  lead,  tetrachloride  of 
ethane,  nitrous  fumes,  trinitrotoluol,  tetryl,  fulminate  of  mercury  and  certain  lubricating 
and  cooling  fluids  (petroleum  products)  used  in  metal  turning  is  pointed  out.  It  is  stated 
that  manipulation  of  tetryl  (tetra-nitro-methylaniline)  which  is  an  explosive,  produces  a 
light  dust  which  may  cause  troublesome  eczema,  also  headache,  drowsiness  and  lack  of 
appetite.  Tetrachloride  of  ethane  is  a  solvent  for  acetate  of  cellulose  and  is  an  ingredient 
of  a  varnish  employed  in  water  proofing  the  canvas  wings  and  bodies  of  aeroplanes. 
Inhalation  of  its  vapor  has  caused  drowsiness,  loss  of  appetite,  constipation,  pains  in  the 
stomach  and  in  more  serious  cases,  jaundice,  liver  destruction,  coma  and  death.  The 
Committee  considers  it  absolutely  necessary  for  those  working  with  these  poisons  to  main- 
tain good  health,  the  evidence  apparently  shows  that  badly  nourished  workers  succumb 
more  readily  than  others. 

REFERENCES 

^  Weyl's  Handb.  d.  Arbeiterkrankh.,  Jena,  1908,  page  184. 

^  Leymann. — Concordia,  1906,  Nos.  7,  8,  9. 

^  Curschmann. — Krankenstatistik.  d.  deutschen  chemisch.     Industrie,  Berlin,  191 1. 

^  Koelsch. — Krankheit  u.  Soziale  Lage  ist  Liefg.  Miinchen,  1912,  page  184. 

*  Rambousek. — Industrial  Poisoning,  London,  1913,  page  42. 

*  Schultze. — Arch.  f.  Soziale  Hygiene,  Vol.  VII,  page  66. 

'  Czaplewski. — Vierteljhschft.  f.  off.  Gesundh.,  191 1,  Vol.  XLIII,  page  356. 

'Lewin,  L. — Zeitschft.  f.  Hygiene  u.  Infect.,  1911,  Vol.  LXVIII,  page  401. 

^  Report  upon  Sanitary  Condition  of  Factories,  etc.,  1907,  page  103. 
10  Rambousek. — Industrial  Poisoning,  London,  1913,  pages  36,  42. 
"  Grempke,  P.  M. — Zeitschft.  f.  Gewerbehygiene,  etc.,  191 2,  Vol.  XIX,  page  65. 
12  Rambousek. — Industrial  Poisoning,  London,  1913,  page  57. 
1'  Hermanni. — Miinch.  Med.  Wochnschft.,  1901,  No.  14,  page,  536. 
^*  Koelsch,  F. — Miinch.  Med.  Woch.,  1914,  page  1869.     Pharm,  J.,  1915,  94,  241. 
"  Neisser. — Internat.  Ubersicht  iiber  Gewerbehygiene,  1907. 

i«  Rambousek. — Actes  dull  Congress  Internat.  des Maladies Professionelles,  Brussels,  1910. 
1^  Ibid.     Industrial  Poisoning,  London,  1913,  page  106. 
18  Rambousek. — Industrial  Poisoning,  London,  1913,  page  107. 
"  Weyl. — Handbuch  d.  Arbeiterkrankheiten,  1908,  pages  204,  208. 

20  Weyl's  Handbuch  d.  Arbeiterkrankheiten,  1908,  pages  204,  208. 

21  Adams,  S.  S. — Trans.  Assoc,  of  Am.  Physicians,  191 2,  page  507. 

22  Oliver's  Dangerous  Trades,  London,  1902,  page  615. 

"  Neisser 's  Internat.  Ubersicht  uber  Gewerbehygiene,  1906,  page  19. 


570        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL  DISEASES 

24  Rambousek. — Industrial  Poisoning,  London,  1913,  pages  212,  213. 

25  Rambousek. — Industrial  Poisoning,  1913,  page  113. 

26  Curschmann,   Fritz. — Actes   du   II   Congress  Internat.    des  Maladies   Professionelles 

Brussels,  1910. 

27  Roth,  E. — Gewerbehygiene,  1907. 

28 Leymann.— Vierteljhschft.  f.  ofif.  Gesundheitspflege  Suppl.,  1902,  page  371. 

29  White  and    Sellers. — Actes  du  II    Congress  Internat.  des  Maladies    Professionelles, 

Brussels,  1910. 

30  Neisser. — Internat.  Ubersicht  iiber  Gewerbehygiene,  Berlin,  1907. 
"  Senn. — Correspondenzbl.  f.  Schweizer  Artze,  1897,  page  161. 

32  Rambousek.— Industrial  Poisoning,  London,  1913,  page  116. 

33  Hayhurst,   E.   R.— Industrial  Health  Hazards  and    Occupational  Diseases    in  Ohio, 

February,  1915. 

34  Sharp.— Editorial  Medical  News,  Vol.  LII,  1888,  page  554. 

35  Mitchell,  J.  K.— Medical  News,  Vol.  LIU,  1888,  pages  150-152. 

3«  Berthenson,  Leo. — Vierteljschft.  offent.  Gesundheitspfl.,  1899,  Bd.  XXX,  page  334. 
3'  Weyls. — Handbuch  d.  Arbeiterkrankh.,  Jena  1908,  page  210. 

33  Report  of  the  Massachusetts  State  Board  of  Health  upon  the  Sanitary  Condition  of 

Factories,  Workshops,  etc.,  1907. 
39  Neisser. — Internat.  Ubersicht  iiber  Gewerbehygiene,  Berlin,  1907,  page  238. 
*"  Rambousek. — Industrial  Poisoning,  London,  19 13,  page  275. 

41  Report  on  the  Sanitary  Condition  of  Factories,  Workshops,  etc.,  1907. 

42  Thompson. — The  Occupational  Diseases,  1914,  page  165. 

43  Doehring,  C.  F.  W. — Factory  Sanitation  and  Labor  Protection.     Bull.  No.  44,  Dept.  of 

Labor,  January,  1903. 
«4  Wodtke.— Vierteljhschft.  f.  Gerichtl.  Med.  u.  ofEentl.  Sanitatswesen,  Vol.  XVIII,  p.  325. 
^5  Munroe,  Charles  E. — U.  S.  Census  Bulletin,  No.  92,  1908. 
46  Hayhurst,  E.  R. — Industrial  Health  Hazards  and  Occupational  Diseases  in  Ohio.     Ohio 

State  Board  of  Health,  Feb.,  1915,  page  345. 
"  Rambousek,  J. — Industrial  Poisons,  London,  1913. 
43  Oliver. — Diseases  of  Occupation,  London,  1908. 
49  Neisser. — Internat.  Ubersicht,  etc. 
^o  Marshall,  Arthur. — Explosives :  Their  Manufacture,  Properties,  Test  and  History.     P. 

Blakiston's  Son  Co.,  Philadelphia,  19 15,  page  224. 
^1  Marshall,  A.—Loc.  cit. 

32  Munroe,  Charles  E. — -Loc.  cit. 

3^  Key,  Cooper  A. — ^Oliver's  Dangerous  Trades,  London,  1902. 

34  Rambousek,  J. — Industrial  Poisons,  London,  1913. 

33  Oliver. — Diseases  of  Occupation,  London,  1908. 
33  Laws,  C.  E. — J.  A.  M.  A.,  LIV,  1910,  page  793. 

37  Evans,  C.  S. — J.  A.  M.  A.,  LVIII,  191 2,  pages  550. 

38  Ebright,  Geo.  E.— J.  A.  M.  A.,  LXII,  1914,  page  201. 

39  Rambousek,  J. — Industrial  Poisons,  London,  1914,  page  47. 

60  Marshall,  A.~Loc.  cit. 

61  Key. — Oliver's  Dangerous  Trades,  London,  1902. 

62  Hayhurst,  E.  R. — Industrial  Health  Hazards  and  Occupational  Diseases  in  Ohio,i9is. 
6-'  Marshall,  A. — Loc.  cit.,  pages  437-449. 

6'  Key. — Loc.  cit. 

63  Munroe. — Loc.  cit. 
66  Key.— Loc.  cit. 

6'  Marshall,  A. — Loc.  cil. 

68  Pirrie,  R.  Reid. — Practitioner,  London,  LXXXVIII,  1912,  page  212. 

39  Oliver,  T. — Diseases  of  Occupation,  London,  1908. 

'9  Luce,  Rey  Vincent,  and  Hamilton,  Alice,  in  J.  A.  M.  A.  for  May  6,  1916. 


CHAPTER  II 
THE  HIDE,  TANNING  AND  ALLIED  INDUSTRIES 

(Involving  exposure  to  anthrax  and  other  occupational  infectious  diseases) 
BY  GEORGE  M.  KOBER,  M.  D.,  Washington,  D.  C. 

Tanning.  Patent  Leather.  Leather  Gloves  and  Mittens.  Brush  and  Broom  Making. 
Curled  Hair.  Furriers  and  Taxidermists.  Upholstery,  Mattress  Making  and 
Feather  Work.     Preventive  Measures. 

The  handling  of  hides  and  skins,  apart  from  being  disagreeable  and  when 
dry  also  very  dusty  work,  is  dangerous  on  account  of  liability  to  wounds 
and  anthrax  infections. 

The  most  common  medium  for  the  transmission  of  anthrax  in  handling 
infected  skins  or  fleeces  is  the  dried  blood  clots  adhering  to  the  hair  or  wool. 
Indeed  so  resistant  are  the  spores  of  anthrax  that  infections  have  occurred 
not  only  among  the  men  handling  the  hides  and  tanners,  but  also  among 
workers  in  the  boot  and  shoe,  harness  and  glove  industries. 

Dr,  E.  W.  Hope,^  the  Medical  Ofi&cer  of  Health  of  Liverpool,  presented 
an  interesting  account  of  60  cases  of  anthrax  studied  in  that  city  during  a 
period  of  8  years;  of  these,  36  cases  occurred  in  dock  laborers,  "and  a  large 
proportion  of  them  were  infected  in  the  unloading  or  carting  of  hides,  either 
loose  or  in  bales." 

In  1905  the  Medical  Inspector^  reported  a  case  which  occurred  in  the  wife 
of  a  dock  laborer  in  South  London,  who  had  been  engaged  in  unloading 
foreign  hides  and  evidently  carried  the  germs  in  his  clothing  to  his  house. 
Another  case  occurred  at  Plymouth  in  a  man  engaged  in  unloading  bones. 
Of  261  cases  of  anthrax  reported  in  Great  Britain,  between  1899  and  1904, 
86  cases  occurred  in  the  hide  and  skin  trade;  and  of  these,  21,  or  24.4  percent., 
proved  fatal.  In  nearly  50  per  cent,  of  the  cases  the  seat  of  the  pustule  was 
in  the  neck,  as  against  29.5  per  cent,  in  the  wool  industry.  This  difference 
has  been  justly  attributed  to  the  habit  of  carrying  the  hides  on  the  shoulders, 
and  is  a  strong  argument  in  favor  of  removal  by  mechanical  means.  Dr. 
Hope^  cites  two  cases  of  anthrax  infection  in  female  bag  menders;  one  of 
the  bags  had  contained  wool  or  hair,  and  the  other,  Egyptian  cattle  bones. 
Cases  have  also  been  reported  in  persons  engaged  in  mending  tarpaulins 
vi^hich  had  been  used  to  cover  wool. 

Dr.  Hope  states  that  the  hides  causing  infection  came  from  all  parts  of 
the  world,  but  chiefly  from  China  and  the  East  Indies.  The  material  causing 
infection  in  the  case  of  hair  was  derived  from  Russian  sources.     He  also 

571 


572        ETIOLOGY   AND   PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

refers  to  the  fact  that  a  large  number  of  bales  are  transhipped  to  the  United 
States.  Since  anthrax  was  extremely  rare  30  years  ago  among  the  domestic 
animals  of  this  country,  the  infections  reported  are  perhaps  chiefly  due  to 
the  importation  of  imported  hides  and  fleeces.  RaveneP  reports  12  cases 
of  anthrax  among  men  and  60  in  cattle,  which  occurred  in  three  localities 
in  Pennsylvania  during  the  summer  of  1897.  All  were  traced  to  a  tannery 
handling  hides  imported  from  China.  The  infection  in  the  cattle  was 
believed  to  be  due  to  feeding  on  pastures  watered  by  streams  contaminated 
by  tannery  refuse.  Similar  instances  have  been  reported  in  different  parts 
of  Europe,  and  indicate  how  imported  infected  hides  may  be  a  source  of 
danger  to  the  animal  industry  in  sections  heretofore  free  from  anthrax, 
and  also  the  danger  to  public  health  of  permitting  tannery  refuse  to  be 
discharged  into  streams,  without  preliminary  treatment. 

Preventive  Measures. — In  most  civilized  countries  stringent  rules  have 
been  adopted  for  the  suppression  of  anthrax  and  other  diseases  communi- 
cable from  animals  to  man.  Among  these  rules  may  be  mentioned:  com- 
pulsory notification  of  the  existence  of  anthrax;  isolation  and  quarantine  of 
the  entire  herd;  prompt  killing  of  the  diseased  animal  and  destruction  of 
the  carcass  by  cremation;  and  thorough  disinfection  of  the  stables  and  other 
infected  premises.  The  owner  is  reimbursed  for  the  loss  sustained.  These 
rules  were  primarily  enacted  in  the  interest  of  animal  husbandry.  The 
question  of  anthrax  infection,  in  its  relation  to  man,  has  been  emphasized 
only  in  recent  years.  In  some  countries,  Germany  for  example,  even  now 
no  compensation  is  paid  for  sheep  and  goats  which  perish  from  this  disease, 
and  as  a  result  the  farmer  is  sorely  tempted  to  sell  such  infected  skins  to 
"fell-mongers." 

Tanning. — This  occupation  calls  for  strength  and  endurance  as  many 
of  the  processes  are  laborious,  extremely  wet,  and  disagreeable,  and  are 
often  carried  on  under  insanitary  conditions.  Indeed,  the  odors  of  "beam 
houses"  are  so  offensive  as  to  be  considered  a  nuisance  to  the  neighborhood. 
The  injurious  influence  of  these  odors  has,  however,  been  overestimated. 

The  handling  of  dried  hides  and  skins  involves  the  inhalation  of  more 
or  less  dust  of  organic  and  inorganic  origin,  fragments  of  hair,  etc.  The 
mortality  rates  in  the  U.  S.  for  1909  show  that  15.2  per  cent,  of  all  the  deaths 
among  tanners  were  caused  by  tuberculosis,  14.3  per  cent,  by  heart  disease, 
8.8  per  cent,  by  pneumonia,  and  8.7  per  cent,  by   Bright's   disease. 

According  to  Popper,^  one-sixth  of  all  the  deaths  are  caused  by  pneumonia 
and  about  40  per  cent,  from  tuberculosis.  Diseases  of  the  digestive  organs 
and  of  the  kidneys  are  not  uncommon.  Rheumatic  and  catarrhal  affections, 
on  account  of  exposure  to  wet  and  sudden  changes,  are  also  quite  prevalent. 
Many  of  the  hides  also  have  sharp  cutting  edges,  which  are  liable  to  produce 
wounds  and  abrasions  and  subsequent  septic  infections.  In  the  handling  of 
lime  skins  and  during  the  removal  of  the  hair,  the  workmen  not  infrequently 
get  short  pieces  of  hair  under  the  finger  nails,  giving  rise  to  septic  conditions. 


THE   HIDE,    TANNING   AND   ALLIED    INDUSTRIES  573 

As  a  result  of  immersion  of  the  hands  in  caustic  lime  solutions  Prof.  Roth' 
refers  to  a  peculiar  affection  of  the  skin,  characterized  by  loss  of  substance 
and  bright  red,  shining  finger  tips,  called  by  the  French  tanners  "rossignol" 
or  ''pigeon"  and  by  the  Germans  "Stieghtz."  Other  skin  and  nail  affec- 
tions are  liable  to  develop,  especially  in  persons  engaged  in  scraping  sheep 
,  and  rabbit  skins  and  also  from  the  use  of  arsenic,  the  chromates  and  acid 
solutions.  The  danger  from  anthrax  infections  constitutes  an  important 
occupational  risk;  63  such  cases  with  14  deaths  occurred  in  German  tanneries 
in  1903-1904,  and  Neisser  reported  29  cases  in  1905,  the  majority  of  which 
were  traced  to  imported  hides.  Of  255  cases  with  45  deaths,  tabulated  by 
Holtzmann,^  which  occurred  in  the  German  leather  industry  between  1906- 
1910,  the  source  of  infection  was  traced  in  154  instances  to  lamb,  sheep  and 
goat  skins,  and  in  loi  instances  to  hides  from  calves,  heifers,  cows,  steers  and 
wild  animals.  It  has  long  been  known  that  the  handling  of  dried  hides  is 
more  dangerous,  and  Dr.  Hamer^  expressed  the  hope  that  the  wet  process 
of  curing  would  diminish  the  spread  of  infection.  But  because  of  the  in- 
creased weight  of  wet  consignments  the  majority  of  imported  hides  are  still 
cured  and  shipped  in  a  dry  state. 

A  number  of  the  tanneries  in  the  Netherlands,  as  a  result  of  long  ex- 
perience, have  come  to  the  conclusion  that  the  dried  hides  are  more  dan- 
gerous as  a  rule,  because  the  countries  from  which  they  are  shipped  pay  little 
or  no  attention  to  the  prevention  of  anthrax.  They  caution  especially  against 
the  purchase  of  hides  with  bayonet  cuts,  as  such  perforations  are  an  indica- 
tion that  the  skin  came  from  a  diseased  animal  which  had  been  killed  for 
the  sake  of  the  hide.  They  also  fear  the  danger  of  arsenic-cured  hides  from 
China.  Lastly,  their  observations  lead  them  to  conclude  that  hides  imported 
from  the  United  States  are  the  least  dangerous,  as  they  came  from  abattoirs 
subject  to  Federal  inspection,  where  none  but  healthy  animals  are  permitted 
to  be  slaughtered. 

Tanning  and  Dressing  Processes. — The  old  method  of  using  tan  bark 
and  sumac  has  been  largely  supplanted  by  the  use  of  chemicals.  As  a  pre- 
liminary to  either  process  the  hides  are  first  soaked  in  water  and  afterward 
in  water  to  which  Hme,  and  sometimes  disulphide  of  arsenic,  has  been  added. 
This  causes  the  hides  to  swell  and  facilitates  the  removal  of  the  fleshy  part  of 
the  hide,  which  with  the  hair  is  scraped  off,  either  by  hand  or  by  suitable 
machinery. 

The  de-hairing  process  is  sometimes  done  in  so-called  "sweat  chambers" 
under  the  influence  of  Hme  or  its  sulphide,  or  of  sodium  sulphate.  The  tem- 
perature in  these  chambers  is  often  above  86°  and  not  only  attracts  flies,  but 
also  favors  the  development  of  ammonium  sulphide  and  of  anthrax  spores, 
if  any  be  present.  After  this  process,  the  hides  are  soaked  in  acidulated  water, 
or  a  bath  containing  animal  excrement,  for  the  removal  of  hme. 

"When  the  hides  or  skins  are  ready  for  the  actual  tanning,  they  are 
placed  either  in  a  vat  containing  the  old-fashioned  tan  bark  Hquor,  or  into  a 


574        ETIOLOGY   AND   PROPHYL.^XIS    OF    OCCUPATIONAL  DISEASES 

revolving  drum  known  as  a  "pin  wheel,"  or  into  a  pit  supplied  with  revolving 
paddles  and  containing  a  dilute  solution  of  potassium  or  sodium  dichromate, 
acidified  with  hydrochloric  or  sulphuric  acid,  and  caused  to  revolve  or 
to  be  overturned  for  7  hours  or  longer,  after  which  time,  if  the  "pin  wheel" 
is  employed,  the  liquor  is  drawn  off  and  replaced  by  an  acidified  solution  of 
sodium  thiosulphate  or  bisulphite  and  the  revolution  is  continued  several 
hours  longer.  If  the  pit  is  used,  the  skins  are  removed  to  another,  containing 
the  second  solution,  and  kept  at  rest  or  overturned  for  a  like  period."^ 

During  these  processes,  the  hands  and  arms  of  the  workmen  are  exposed 
to  the  caustic  and  toxic  effects  of  Hme,  chromates,  etc.  Dr.  Neisser^*'  reports 
a  number  of  cases  of  pustular  eczema  in  chrome-tanning  workers  and  19  cases 
.  of  chrome  ulcers  among  300  workers  within  i  year.  He  also  reports  similar 
instalices  in  connection  with  the  tanning  industry,  resulting  from  the  vapors 
developed  in  dissolving  the  chrome  in  hot  water.  Protection  with  long 
rubber  gloves  does  not  always  prevent  troublesome  skin  affections.  In  es- 
tablishments in  which  arsenic-cured  hides  are  handled,  or  realgar  or  orpiment 
is  used  as  a  chemical  agent,  there  is  a  certain  amount  of  danger  from  arsenical 
poisoning. 

There  is  more  or  less  danger  from  lead  poisoning  during  the  finishing 
process  of  alum- tanned  leather,  which  is  rubbed  with  a  mixture  of  talcum  and 
white  lead.  Cases  of  lead  poisoning  have  also  been  observed  in  men  who, 
while  tacking  the  hides  on  frames,  are  in  the  habit  of  holding  the  tinned 
tacks  in  their  mouth.  This  habit  is  also  objectionable  from  the  fact  that, 
sometimes,  they  have  been  spilled  previously  on  the  floor  and  are  picked  up 
and  without  washing  placed  in  the  mouth  and  may  thus  be  the  means  of  con- 
veying disease  germs.  In  the  subsequent  processes  of  leather  dressing  there 
is  more  or  less  danger  from  unprotected  machinery.  In  the  buffing  process, 
which  is  characteristic  of  chrome-tanned  leather,  and  which  is  done  by  means 
of  wheels  or  revolving  drums  covered  with  sandpaper,  the  air  of  the  room  is 
frequently  filled  with  very  fine  dust,  presumably  containing  chromates.  Since 
aniline  dye  stuffs  and  orpiment  are  used  in  the  manufacture  of  "fancy  leather," 
we  may  expect  to  find  aniline  and  arsenical  skin  eruptions  and  even  symptoms 
of  systemic  poisoning.  Benzine  is  freely  used  as  a  solvent  for  the  various 
dye  stuffs.  Dr.  W.  G.  Thompson^^  reports  a  case  of  multiple  neuritis  of 
both  arms  in  a  finisher  of  leather,  caused  by  arsenic  which  had  been  used 
as  a  tanning  agent  and  was  evidently  disengaged  during  the  rubbing  and 
polishing  process. 

Patent  Leather. — The  manufacture  of  patent  leather  is  largely  a  secret 
process,  but  sufficient  is  known  to  indicate  that  the  workmen  are  exposed  to 
such  industrial  poisons  as  lead,  amyl  acetate  (zapone  lacquer),  naphtha,  and 
wood  alcohol,  which  are  some  of  the  ingredients  of  a  mixture  with  which  the 
leather  is  coated.  This  mixture,  after  being  heated  in  iron  kettles,  is  apphed 
to  the  hide,  stretched  on  frames,  and  evolves  fumes  which,  even  employers 
admit,  cannot  be  withstood  by  the  workmen  for  any  length  of  time.     The 


THE   HIDE,    TANNING   AND    ALLIED    INDUSTRIES  575 

men  generally  work  stripped  to  the  waist.  "In  one  of  the  two  factories 
visited  the  odor  of  naphtha  was  noticeable  in  every  department."  Naphtha 
"drunks"  were  said  to  be  not  uncommon  among  the  workers.  The  minors 
at  work  were  all  Italians,  young  and  rugged,  recently  landed,  so  that  the 
occupation  had  not  as  yet  affected  them.^^ 

Preventive  Measures. — It  is  needless  to  insist  that  this  occupation  is 
intrinsically  dangerous  to  health  and  that  the  utmost  precautions  should  be 
exercised  to  safeguard,  by  adequate  exhaust  ventilation,  the  health  of  the 
employees. 

The  Leather  Glove  and  Mitten  Industry. — The  average  number  of  persons 
employed  in  this  industry  in  this  country  during  the  year  1909  was  12,950, 
of  whom  48  per  cent,  were  males  and  52  per  cent,  females.  The  average 
number  of  children  under  16  years  of  age  was  269.  The  working  hours 
averaged  between  54  and  60  hours  per  week.^^ 

The  industry  involves  exposure  to  dust  and  toxic  dyes  and  agents  used 
in  the  preparation  of  the  leather.  The  work  is  often  carried  on  under  unfav- 
orable environments.  Diseases  of  the  respiratory  organs,  caused  by  exposure 
to  bad  air  and  dust,  especially  in  the  buffing  process,  are  most  frequent,  and 
tuberculosis  is  responsible  for  60  per  cent,  of  all  the  deaths.  Catarrhal  af- 
fections, conjunctivitis,  diseases  of  the  digestive  organs,  varicose  veins  and 
leg  ulcers  are  not  uncommon.  Occasional  cases  of  lead  poisoning,  from  the 
use  of  talcum  and  white  lead,  and  isolated  instances  of  anthrax  infection 
have  been  reported.  Persons  engaged  in  the  dyeing  process  not  infrequently 
develop  chrome  ulcers  on  the  thumb  of  the  left  hand  and  on  the  second  and 
third  fingers  of  the  right  hand.  Another  form  of  ulceration  has  been  observed 
between  the  toes  of  employees,  who  are  in  the  habit  of  using  their  bare  feet 
for  the  purpose  of  soaking  the  leather  in  tubs.  The  alum  used  for  tanning 
purposes  and  failure  to  wash  and  dry  the  feet  properly  is  believed  by  Bauer^* 
to  be  the  cause  of  these  ulcers.  Callosities  of  the  hands  and  contracted 
tendons  are  also  observed. 

Preventive  Measures — All  home  work  should  be  discouraged  and  the 
industry  should  be  carried  on  in  sanitary  shops  properly  quipped  with  ex- 
haust ventilation  for  the  removal  of  dust  and  vapors. 

Brush  and  Broom  Making. — In  the  manufacture  of  brushes,  hog  bristles 
and  vegetable  fiber  are  chiefly  used;  for  the  more  delicate  brushes,  horse- 
hair, goat,  camel  and  cattle  hair,  and  hog  wool  are  employed.  The  handling 
of  these  hairs  in  a  raw  state  is  a  dirty,  dusty  and  even  a  dangerous  process, 
on  account  of  the  possibility  of  anthrax  infection. 

Of  the  60  cases  of  anthrax  infection  reported  by  Dr.  Hope  in  191 2, 
7  contracted  the  disease  in  handling  horsehair  or  bristles  in  hair  factories; 
14  cases  with  7  deaths  occurred  in  German  hair  and  brush  factories  in  1904." 
It  is  usual  and  necessary,  therefore,  to  boil  the  bristles  for  several  hours, 
after  which  they  are  dried  in  steam  dryers  and  bleached,  and  then  dressed 
or  combed  by  machinery  and  mixed.     In  the  manufacture  of  paint,  varnish 


576        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

and  kalsomine  brushes,  the  bristles  are  set  into  the  handles  by  means  of  a 
tar  cement  or  a  cement  composed  of  wood  alcohol  and  shellac;  for  shaving 
brushes,  a  cement  of  rosin  and  Hnseed-oil  is  used,  which  is  kept  fluid  by- 
means  of  electric  or  non-luminous  gas  flame  heaters,  provided  with  hoods. 
Hirt  reports  that  nearly  one-half  of  all  the  deaths  among  brush  makers 
are  caused  by  consumption.  The  danger  is  probably  due  to  the  irritation 
produced  by  the  inhalation  of  sharp  fragments  of  bristles,  which  are  not 
easily  dislodged.  Instances  of  lead  poisoning  have  also  been  reported  in 
this  industry. 

In  the  nine  factories  reported  upon  by  the  Massachusetts  State  Board 
of  Health^*  "  the  dust  removal  appliances  were  found  to  be  fairly  good,  satis- 
factory and  even  excellent,"  and  the  health  of  the  employees,  mostly  women 
and  girls,  "appeared  to  be  fair  or  good." 

When  vegetable  fiber  is  used,  dust  production  is  also  very  great.  This 
is  especially  true  in  the  manufacture  of  "corn  brooms."  This  danger  is 
recognized,  so  that  hooded  stripping  machines,  provided  with  a  chamber  for 
the  removal  of  dust,  seeds,  and  other  foreign  material,  have  been  installed. 
In  some  establishments  the  "wet  process"  has  been  adopted  before  removal 
of  the  seeds  and  dust.  The  bleaching  process  involves  exposure  to  sulphur 
and  chlorine  fumes;  aniline  solutions  are  used  for  dyeing  and  staining  purposes. 
Fatigue  from  piecework,  long  hours,  jarring  processes,  faulty  position  and 
unfavorable  working  conditions  are  among  the  occupational  hazards  ob- 
served in  this  industry. 

Curled  Hair  and  Horse-hair  Cloth  Factories. — In  all  of  these  industries, 
apart  from  the  inhalations  of  mixed  dust  and  of  minute  fragments  of  hair, 
there  is  danger  of  anthrax  infection  and  other  communicable  diseases. 
Of  the  261  cases  of  anthrax  reported  in  Great  Britain  between  1899  and  1904, 
70  cases  occurred  in  the  hair  industry.  Nichols^^  of  this  country  reported 
26  cases,  which  occurred  in  one  curled  hair  factory  in  3  years.  The  Massa- 
chusetts State  Board  of  Health  for  1908  reports  four  cases  of  malignant 
pustule,  in  a  curled  hair  shop,  during  a  period  of  7  years.  Since  the  man- 
agement adopted  a  method  of  disinfection,  by  prolonged  fumigation  with 
formaldehyde  and  subsequent  boiling  of  the  hair,  no  cases  have  occurred. 
A  peculiar  painful  affection  of  the  finger  tips,  extending  at  times  to  the 
margin  of  the  finger  nails,  has  been  observed  in  some  of  the  employees  in 
hair  cloth  factories  in  France. 

Furriers  and  Taxidermists. — A  similar  affection,  but  more  especially 
limited  to  the  finger  nails  of  men  engaged  in  scraping  rabbit  and  hare 
skins,  was  reported  by  Dr.  Gilbert  of  Brussels  in  1896.  It  was  noticed  in 
18  of  the  22  workmen  examined  by  him.  The  character  and  amount  of 
dust  evolved  in  the  various  processes  of  the  fur  industry  are  doubtless  factors 
in  the  development  of  respiratory  diseases.  This  is  especially  true  in  the 
manufacture  of  artificial  furs  and  the  preparation  of  rabbit  fur  for  the  felt 
hat  industry.     But  in  the  manipulation  of  all  kinds  of  fur,  there  is  more  or 


THE   HIDE,    TANNING   AND   ALLIED    INDUSTRIES  577 

less  dust  inhalation,  incident  to  repeated  brushing,  fur  pulling  and  clipping, 
and  such  dust  not  infrequently  harbors  disease  germs.  Dr.  W.  G.  Thompson'^ 
states  that  pulmonary  abscess  is  very  common  among  the  employees  of  a  fur- 
manufacturing  establishment  in  the  State  of  New  York.  Arsenious  acid 
in  the  proportion  of  i  lb.  to  the  gallon  of  water  is  often  employed  by  furriers 
and  taxidermists  as  a  preservative.  An  American  chemist  demonstrated  its 
presence  in  11  of  the  42  samples  examined,  amounting  i^  some  instances 
to  170  grains  per  square  yard.  Many  of  the  furs  are  in  whole  or  in  part 
dyed  with  lead  pigments,  which  constitutes  an  additional  source  of  danger. 

A  clinical  and  sanitary  study  of  the  fur  and  hatter's  fur  trade  has  recently 
been  conducted  by  the  Department  of  Public  Health  in  the  City  of  New 
York  (see  Monthly  Bulletin  for  October,  1915). 

Of  3839  persons  engaged  in  dressing,  dyeing  or  manufacturing  fur,  a 
complete  physical  examination  was  made  of  542  persons.  Of  these,  67 
individuals  suffered  from  anaemia  and  18  others  showed  marked  malnu- 
trition; 12  persons  suffered  from  furrier's  asthma;  32  from  subacute  and 
chronic  bronchitis;  11  from  tuberculosis  and  7  from  emphysema;  163  suf- 
fered from  skin  diseases;  151  from  nose  and  throat  affections;  74  from  dis- 
eases of  the  heart;  89  from  ocular  defects;  50  from  dental  defects;  and  35 
from  orthopedic  defects,  inclusive  of  14  cases  of  varicose  veins  and  10  of 
flat-foot. 

A  number  of  the  dyers  and  dressers  showed  the  presence  of  dye  pigments 
and  sawdust  in  their  nostrils.  The  nails  of  dyers  frequently  revealed  de- 
formities. CaUus  formations  on  the  fingers,  hands  and  on  the  flexor  surface 
of  the  wrists  were  not  uncommon  in  cutters,  dressers  and  beaters.  Only 
77  individuals  of  those  examined  (about  14  per  cent.)  were  found  free  from 
physical  defects. 

Preventive  Measures. — Reference  has  already  been  made  to  the  danger 
of  mercurial  poisoning  involved  in  the  manufacture  of  felt  hats.  It  is  need- 
less to  insist  that  adequate  exhaust  ventilation  should  be  provided.  It  is 
gratifying  to  note  that  the  morbidity  in  establishments  which  have  provided 
such  safeguards  has  been  reduced  fully  one-half. 

Upholstery,  Mattress  Making  and  Feather  Work.^These  occupations 
have  always  been  regarded  as  unhealthful,  on  account  of  the  inhalation  of 
dust  incident  to  the  manipulation  of  hair,  wool,  cotton,  felt,  excelsior, 
feathers,  and  other  material.  Even  when  new  material  is  used,  unless  it 
has  been  thoroughly  washed  and  disinfected,  the  process  of  picking  and 
carding  involves  the  inhalation  of  large  amounts  of  dust  which  may  con- 
tain disease  germs,  and  which  predisposes  to  respiratory  diseases,  anthrax 
infections,  etc.  All  these  dangers  are  enormously  increased  when  second- 
hand material  is  handled,  as  in  the  renovation  of  mattresses,  feather  beds, 
bolsters,  pillows,  furniture  cushions,  etc.,  especially  when  such  articles  have 
been  used  by  infectious  patients. 

It  is  not  surprising  that  a  French  Commission  should  have  found  that 
37 


578        ETIOLOGY   AND   PROPHYLAXIS    OF   OCCUPATIONAL   DISEASES 

"old  mattresses  are  often  the  means  of  spreading  the  germs  or  virus  of 
smallpox,  erysipelas,  scarlet  fever,  diphtheria,  measles  and  typhoid  fever." 
As  a  matter  of  fact,  among  the  few  cases  of  smallpox  reported  in  Germany 
in  1905^°  several  were  traced  to  a  feather  bed  renovating  establishment  at 
Pilsen.  The  dangers  of  handling  even  new  feathers  imported  from  Russia, 
China  and  countries  where  smallpox  prevails  have  been  pointed  out  by 
Shablowsky.-^  In  the  opinion  of  Sir  Thomas  Oliver^^  feather  dust  is  liable  to 
produce  ophthalmia  and  diseases  of  the  respiratory  organs. 

Preventive  Measures. — Fortunately  in  most  of  these  occupations  hooded 
machines  with  exhaust  ventilation  have  taken  the  place  of  hand  labor  in 
the  picking  and  carding  processes  of  hair,  wool  and  other  material;  but  in 
spite  of  dust-removing  devices,  more  or  less  dust  escapes,  and  every  efifort 
should  be  made  to  render  them  more  efifective.  A  more  general  adoption 
of  the  wet  processes  will  be  a  great  aid.  Even  if  the  dust  is  free  from  disease 
germs,  the  inhalation  of  minute  fragments  of  hair  and  organic  and  inorganic 
matter,  some  of  which  is  derived  from  the  perspiration  of  animals  which 
has  dried  on  the  hair  of  horses,  etc.,  doubtless  predisposes  to  diseases  of 
the  respiratory  system.  It  is  well  known  that  cavalry  troops  are  more 
susceptible  to  pneumonia  than  other  arms  of  the  service.  The  writer  in 
1886  pointed  out  that  the  inhalation  of  organic  dust,  evolved  in  the  groom- 
ing of  horses,  was  a  possible  predisposing  factor. 

There  is  no  question  that  old  as  well  as  new  material  of  animal  origin 
should  first  be  subjected  to  disinfection,  by  means  of  steam  under  pressure, 
by  formaldehyde,  or  by  boiling.  Old  and  worthless  bedding,  used  by  in- 
fectious patients,  should  be  burned.  The  precautions  for  the  prevention 
of  anthrax,  especially  in  the  handling  of  imported  hides,  hair  and  wool, 
have  been  described  on  page  572,  but  as  it  is  extremely  difficult  to  kill  the 
spores  of  anthrax,  it  is  desirable  that  the  workers  should  be  informed  of 
the  dangers,  and  their  cooperation  secured  in  the  prevention  of  this  industrial 
infection.  Wounds  and  abrasions,  pimples  and  skin  affections  should 
receive  prompt  attention.     (See  also  page  158.) 

A  most  praiseworthy  example  has  been  set  by  the  Pachetti  Bros.,  own- 
ers of  a  hair-cloth  factory  in  Milan  in  which  700  persons  are  employed. 
Although  the  horsehair  is  disinfected  by  steam  under  pressure,  a  physician 
makes  daily  visits,  treats  all  wounds  and  abrasions,  and  examines  all  cases 
of  indisposition,  with  special  reference  to  anthrax  infection.  His  office  is 
equipped  with  apparatus  for  a  bacteriological  diagnosis  and  the  prompt 
administration  of  Sclavo's  serum. 

Robinson  and  Wilson-'  refer  to  the  occupational  hazards  in  the  the  leather  industry  in 
Cincinnati.  Among  197  men  employed  in  the  manufacture  of  leather,  3  or  1.5  per  cent, 
were  found  to  be  tuberculous.  In  one  of  these  cases  the  occupation  was  in  no  way  related 
to  the  immediate  cause  of  the  disease.  The  low  incidence  of  tuberculosis  among  a  class  of 
workers  exposed  to  many  deleterious  influences  is  attributed  largely  to  the  selection  of 
strong  able-bodied  men,  sufTicient  air  and  floor  space,  favorable  working  conditions  as  re- 
gards temperature  and  humidity  after  the  hides  have  left  the  vat,  and  the  fact  that  over 


THE   HIDE,    TANNING   AND    ALLIED    INDUSTRIES  579 

50  per  cent,  of  the  men  examined  were  more  than  35  j^ears  old  and  hence  beyond  the  sus- 
ceptible age. 

Among  57  men  engaged  in  the  manufacture  of  harness  and  saddles,  3  or  5.2  per  cent, 
weie  found  to  be  tuberculous.  The  investigators  consider  the  number  examined  too  small 
to  hold  the  industry  responsible  for  the  high  percentage,  since  with  the  exception  of  the 
collar-making  department,  there  is  little  exposure  to  dust.  The  collars  are  stuffed  with  rye 
straw  and  chaff,  and  the  operations  are  attended  with  much  dust,  but  the  blowers  connected 
with  the  cutting  and  stufi&ng  machines  carried  away  most  of  the  dust.  Moreover  none  of 
the  tuberculous  subjects  were  working  in  this  department. 

AH  of  the  14  workers  employed  in  two  broom  factories  were  found  to  be  in  good  health  and 
presented  no  evidence  of  tuberculosis,  in  spite  of  poor  light  and  ventilation,  and  promis- 
cuous spitting.  Of  48  persons  engaged  in  the  manufacture  oi  feather  pillows,  cushions  and 
bedding  goods  only  one  tuberculous  subject  was  found.  No  history  obtainable.  All  dust 
producing  machines  were  supplied  with  exhaust  fans. 

REFERENCES 

*  Hope,  E.  W. — The  Incidence  of  Industrial  Anthrax  in  Liverpool.     Trans.  15th  Internat. 

Congress  on  Hygiene,  Sec.  IV,  Wash.,  D.  C,  Vol.  Ill,  Part  II,  1913,  page  735. 
^  Neisser. — Internat.  Ubersicht  iiber  Gewerbehygiene,  Berlin,  1907,  page  84. 
'  Hope,  E.  W.—Op.  cit. 

*  Ravenel. — Philadelphia  Med.  Journal,  Apr.  22,  1899,  page  897. 

*  Popper. — ^Lehrbuch  der  Arbeiterkrankheiten,  1908. 

*  Roth,  E. — Gewerbehygiene,  1906,  page  121. 

'  Holtzmann. — Viertelj.  fiir  offentl.  Gesundheitspf.,  1912,  Vol.  XLIV,  page  444. 

*  Oliver's  Dangerous  Trades,  1902,  page  633. 

*  Report  of  the  Mass.  State  Board  of  Health  upon  the  Sanitary  Conditions  of  Factories 

etc.,  1907,  page  116. 
1"  Neisser. — Internat.  Ubersicht  iiber  Gewerbehygiene,  1907,  page  92. 
"Thompson,  W.  G. — ^Trans.  15th  Internat.  Congress  on  Hygiene,  Washington,  Vol.  Ill, 

Part  II,  1913. 
12  Report  of  the  Mass.  State  Board  of  Health,  1908,  page  31. 
''  U.  S.  census  for  1910. 

1*  Bauer. — Weyl's  Handbuch  d.  Arbeiterkrankh.,  Jena,  1908,  page  509. 
*5  Mass.  State  Board  of  Health,  1907,  page  12;  1908,  page  44. 
"  Hope,  E.  W. — Trans.  15th  Internat.  Congress  on  Hygiene,  etc..  Wash.,  D.  C,  Vol.  Ill, 

Part  II,  1913. 
"  Neisser. — Internat.  Ubersicht  iiber  Gewerbehygiene,  Berlin,  1907. 
"  Second  Annual  Report  of  the  State  Board  of  Health  of  Mass.,  page  86. 
1'  Trans.  15th  Internat.  Congress  on  Hygiene,  Washington,  D.  C,  Vol.  Ill,  Part  II,  1913, 

page  834. 
*"  Neisser. — Internat.  Ubersicht  uber  Gewerbehygiene,  1907,  page  96. 
"  Shablowsky. — Zeitschft.  f.  Hygiene,  etc.,  191 1,  Vol.  LXVIII,  page  209. 
"  Oliver's  Dangerous  Trades,  London,  1902. 
"  Robinson,  D.  E.,  and  Wilson,  J.  G.— U.  S.  Public  Health  Bulletin,  No.  73,  March,  1916, 

page  39. 


CHAPTER  III 
THE  GOLD,  SILVER,  JEWELRY  AND  ALLIED  INDUSTRIES 

BY  GEORGE  M.  KOBER,  M.  D.,  Washington.  D.  C. 

Gold  Mining  and  Extraction.  Goldsmiths.  Cheap  Jewelry  and  Electroplating.  Silver- 
smiths. Manufacture  of  Watches  and  Clocks.  Leaf  Metal  Workers.  Nickel  and 
Nickel  Plating.     Iron  Carbonyl.     Preventive  Measures. 

Gold  Mining. — The  dangers  of  gold  mining  do  not  differ  from  those  of 
metalliferous  mines  in  general;  indeed  they  are  probably  less  in  alluvial  and 
placer  mines.  In  quartz  mines,  however,  the  men  are  exposed  to  a  very 
irritant  dust  as  shown  by  an  alarming  prevalence  of  pulmonary  diseases, 
especially  in  the  gold  fields  of  the  Transvaal  and  at  Bendigo.  The  dust  is 
generated  not  only  during  the  driUing  and  blasting  of  the  hard  quartzite 
rock,  but  the  men  are  exposed  also  during  the  transport  of  the  conglomerate 
to  the  surface  and  the  subsequent  crushing  in  the  stamp  mills.  (See  dust 
prevention,  page  440.) 

Extraction  of  Gold. — After  repeated  washing  of  the  crushed  ore  the  gold 
is  extracted  by  amalgamation  with  mercury,  which  takes  up  the  gold  and 
from  which  it  is  recovered  by  raising  the  temperature  to  400°C.  This 
involves  danger  from  mercurial  poisoning,  especially  during  the  retorting 
process.  """"* 

The  cyanide  of  potassium  process  is  now  generally  employed  as  a  sub- 
stitute for  the  more  dangerous  mercurial  process.  In  this  process  the 
crushed  ore  is  placed  in  vats  containing  a  0.05  to  0.5  per  cent,  solution  of 
cyanide  of  potassium,  where  it  remains  from  12  to  24  hours  or  longer  accord- 
ing to  the  character  of  the  ore.  The  liquor  is  then  passed  over  pure  metallic 
zinc  shaving,  upon  which  the  gold  is  deposited  as  a  slime.  This  slime  is 
roasted  and  smelted  and  pure  gold  is  obtained.  Work  with  the  cyanide 
solution^  however,  involves  exposure  to  cyanogen  vapors  unless  guarded 
against  by  copious  ventilation,  and  also  necessitates  the  use  of  rubber  gloves 
in  order  to  avoid  troublesome  eczema  of  the  hands  and  arms. 

Silver  is  likewise  recovered  from  crushed  ore  by  amalgamation  with 
mercury,  and  considerable  quantities  are  obtained  from  lead  ore  during 
the  roasting  of  which  there  is  a  certain  amount  of  danger  frornjead^-arsenic 
and  antimonyjoisoning.     (See  lead  smelting,  page  78.) 

Gold  and  silver  apparently  possess  no  serious  toxic  properties.  Cases  of 
argyria,  i.e.,  a  brownish-black  discoloration  of  the  skin  as  a  result  of  ingestion 
or  penetration  of  silver  dust,  have  been  reported  in  silver  workers.  Koelsch^ 
describes  two  cases  in  silver  leaf  workers.  Most  of  the  cases  have  been  ob- 
served among  workers  in  the  glass-pearl  industry,  who  employ  a  solution  of 

580 


THE    JEWELRY    AND    ALLIED    INDUSTRIES  581 

nitrate  of  silver  for  silvering  purposes  and  apply  suction  by  the  mouth. 
This  danger  has  been  obviated  by  the  use  of  air  pumps.  Cases  of  local  argyria 
have  been  observed  in  photographers  and  mirror  platers. 

Goldsmiths. — The  manufacture  of  jewelry  afiFords  employment  to  a  large 
number  of  persons,  including  females  and  minors;  of  5753  persons  emploved 
in  various  jewelry  establishments  in  Massachusetts^  there  were  3504  males 
and  2219  females,  including  442  girls  and  260  boys.  The  Sanitary  Inspector 
found,  what  is  quite  generally  the  case,  a  tendency  to  overcrowding;  this 
together  with  a  stooped  position  over  bench  work,  in  the  absence  of  adjustable 
seats,  and  a  high  temperature  of  the  room  constitute  in  themselves  injurious 
factors,  aggravated  by  dust,  acid  fumes  and  other  conditions,  such  as  fatigue 
due  to  eye  strain  incident  to  the  various  processes  which  will  be  briefly 
alluded  to.  The  mortality  rate  from  diseases  of  the  lungs  in  the  Berlin 
goldsmiths^  from  1886-1893  was  42.5  per  cent.,  inclusive  of  40.2  per  cent, 
from  tuberculosis. 

The  basis  for  all  kinds  of  jewelry  is  what  is  known  as  "flat  stock,"  which 
is  made  by  sweating  on  bars  of  gold  by  means  of  silver  solder  to  bars  of  brass 
of  the  same  width  in  a  gas  furnace  to  a  cherry  red  which  results  in  a  firm 
fusion.  This  process  is  necessarily  attended  with  exposure  to  excessive 
heat  and  should  never_hp  rarnVH  nn_ln  the  general  workroom.  The  bars  are 
then  rolled  to  any  desired  thickness,  the  gold  spreading  equally  with  the 
brass,  and  from  this  "flat  stock"  both  tubing  and  wire  may  be  made  suitable 
for  bracelets,  slides,  watch  chains  and  ornaments  of  every  description.  The 
patterns  for  the  flat  ware  are  struck  by  means  of  a  steel  die  and  cut  out  in 
steel  presses.  The  several  parts  are  then  soldered  together  usually  by  female 
labor;  the  process  involves  the  use  of  Bunsen  burners  and  blowpipes,  and 
although  an  ingenious  substitute  for  the  blowpipe  operated  by  compressed 
air  has  been  employed  in  Germany,  the  work  which  is  done  within  16  in. 
from  the  eyes,  involves  not  only  eye  strain,  but  also  exposure  to  heat,  in- 
halation of  the  products  of  combustion,  and  possibly  of  coal  gas  from  defect- 
ive rubber  tubings  and  burners.  After  soldering,  the  piece  is  placed  in  a 
5  to  20  per  cent,  solution  of  sulphuric  acid  for  the  removal  of  borax  and  is 
then  polished  with  cotton  cloth  wheels  and  bristle  brushes.  The  polishing 
wheels  are  provided  with  eflScient  hoods  and  exhausts  so  that  the  dust  may  be 
collected  under  water  in  suitable  tanks  for  the  ultimate  recovery  of  the  gold 
and  silver.  The  final  finish  consists  in  the  application  of  a  weak  solution 
of  potassium  cyanide  and  gold;  this  is  applied  steaming  hot  in  open  crocks 
or  sinks,  not  infrequently  located  in  the  center  of  the  room. 

Cheap  Jewelry  and  Electroplating. — The  manufacture  of  cheap  jewelry, 
ornaments,  etc.,  is  a  growing  industry  both  here  and  abroad;  suffice  it  to 
say  that  most  of  these  trinkets  are  merely  plated  brass  goods,  which  are  first 
cleaned  by  means  of  an  acid  bath  containing  nitric  or  muriatic  acid,  although 
sulphuric  acid  is  sometimes  used.  This  dipping  process  in  hot  acid  solutions, 
apart  from  being  a  frequent  cause  of  eczema  of  the  hands  and  arms,  also 


582        ETIOLOGY   AND   PROPHYL.\XIS    OF    OCCUPATIONAL  DISEASES 

exposes  the  workmen  to  injurious  fumes.  The  goods  are  then  washed  off  in 
ammonia  solutions  and  dipped  in  the  electroplating  bath  consisting  usually 
of  gold  or  silver  dissolved  in  a  solution  of  potassium  cyanide,  the  fumes  of 
which  constitute  the  chief  element  of  danger.  (See  also  copper,  nickel,  tin 
and  zinc  plating.)  Occasional  cases  of  lead  and  mercurial  poisoning  have 
been  observed  in  galvano-plastic  operations  and  also  in  the  refinement  of 
gold  and  silver. 

Plated  goods  are  not  polished  but  they  are  subjected  either  to  the  so- 
called  scratch  brushing  process,  or  various  enamels  and  lacquers  are  employed 
to  prevent  tarnishing.  Zapone  lacquer  is  quite  generally  used  and  the 
observations  of  employees  of  the  State  Board  of  Health  in  Massachusetts  as 
to  its  effects  upon  the  health  of  some  of  the  female  employees  indicate  the 
wisdom  of  placing  it  in  the  list  of  industrial  poisons.  (See  Amyl  Acetate,  page 
721.) 

The  machinery  used  in  the  jewelry  industry  includes  power  presses,  foot 
presses,  stamps,  rolHng  mills,  large  and  small  lathes,  milling  and  grinding  ma- 
chines, planers,  grindstones,  small  sand  blasts,  emery  and  cotton  wheels. 
Occasional  injuries  to  the  fingers  occur  in  operating  the  stamp  and  pressing 
machines.  Dr.  Baum,"*  a  female  Medical  Inspector,  has  called  attention 
to  the  fact  that  miscarriages  and  premature  births  are  quite  frequent  among 
the  women  employed  in  the  Pforzheim  jewelry  industry  and  attributes  this 
largely  to  the  use  of  the  foot  power  presses.  The  writer  feels  disposed  to 
raise  the  question  whether  the  constant  handling  of  brass  goods  may  not 
cause  a  subtle  form  of  lead  poisoning  to  which  the  embryo  is  peculiarly  sus- 
ceptible. 

The  materials  employed  in  the  manufacture  of  jewelry  besides  those 
mentioned  also  includes  aluminum,  precious  and  imitation  jewels,  celluloid, 
glass  and  pearls;  in  fact  quite  a  number  of  establishments  are  also  engaged 
in  the  manufcture  of  pearl  goods. 

Silversmiths. — The  hygiene  of  silversmithing  does  not  essentially 
differ  from  the  industry  just  described;  both  occupations  are  sought  by  weak- 
lings and  the  working  conditions  tend  to  produce  not  only  pulmonary 
diseases  but  also  visual  defects,  because  much  of  the  work  is  done  at  close 
range  and  unless  the  light  is  sufficiently  ample,  eye  strain  results.  On  the 
other  hand,  if  the  light  is  too  glaring,  or  the  persons  handle  highly  reflecting 
surfaces,  irritation  and  hyperaesthesia  of  the  retina  is  apt  to  develop.  This 
condition  is  by  no  means  uncommon  in  polishers  of  silver  or  silver-plated 
ware. 

Preventive  Measures. — The  most  injurious  factors  in  these  industries  are 
exposure  to  vitiated  and  often  overheated  air,  dust  of  a  mixed  character, 
acid  fumes,  the  vapors  of  cyanogen  compounds,  ammonia,  zapone  lacquer 
and  of  glacial  acetic  acid,  while  the  odor  of  sour  beer,  solutions  of  soda,  bran 
and  shorts  and  soap  tree  bark  employed  in  the  "scratch-brushing"  process 
are  also  more  or  less  offensive.     All  these  dangers  can  be  reduced  to  a  mini- 


THE    JEWELRY   AND    ALLIED   INDUSTRIES  583 

mum  by  efficient  exhaust  ventilation,  separate  rooms  for  the  "dipping" 
department,  provided  with  suitable  hoods  and  suction  apparatus.  The 
persons  engaged  in  the  "  dipping  process"  should  either  handle  the  goods  with 
wooden  tongs  or  protect  their  hands  with  zinc  ointment  or  rubber  gloves  in 
order  to  avoid  troublesome  affections  of  the  skin. 

Manufacture  of  Watches  and  Clocks. — In  this  industry  there  is  likewise 
a  tendency  to  overcrowding,  and  failure  to  provide  adjustable  seats  for  bench 
work.  The  lighting  of  the  rooms  is  often  defective,  causing  eye  strain  in 
about  10  per  cent,  of  those  engaged  in  the  work  (Cohn). 

The  injurious  factors,  apart  from  exposure  to  dust  derived  from  gold, 
silver,  steel,  copper,  brass  and  the  material  used  for  enamel,  are  the  fumes 
of  nitric  acid  evolved  in  the  enameling  process  of  dials,  etc.  The  latter  process 
and  the  tempering  of  watch  and  clock  springs,  and  the  casting  of  leaden 
weights  also  involve  exposure  to  lead.  The  fumes  of  benzine  and  of  cyanide 
evolved  in  cleaning  the  small  parts  are  likewise  inimical  to  health.  The  Berlin 
statistics^  from  1892-97  show  that  50  per  cent,  of  all  the  deaths  in  this  industry 
were  caused  by  tuberculosis  and  the  average  age  was  only  27.8  years.  This 
may  in  part  be  accounted  for  by  the  fact  that  many  persons  with  feeble 
physique  enter  this  industry,  but  the  bad  working  conditions  are  also 
important  contributory  factors. 

Preventive  Measures. — ^Most  commendable  efforts  are  made  in  modern 
establishments  to  provide  proper  safeguards  in  the  way  of  air-space,  light  and 
ventilation,  with  mechanical  devices  for  the  arrest  and  removal  of  dust  and 
fumes  at  the  point  of  their  origin.  In  one  of  the  German  establishments  the 
tempering  furnaces  are  supplied  not  only  with  exhaust  ventilation  but  also 
with  a  pyrometer,  in  order  that  the  operators  can  observe  the  color  of  the 
steel  without  exposure  to  the  vapors. 

Leaf  Metal  Workers. — The  metal  employed  for  gold  leaf,  silver,  bronze, 
aluminum,  or  other  composition,  usually  an  alloy  of  copper  and  zinc,  is  first 
rolled  into  thin  sheets  and  subsequently  hammered  into  the  finest  sheets  in- 
closed in  parchment  paper.  The  hammers  weigh  from  6  to  24  lb.  and  the 
workmen  lift  this  weight  about  90  times  every  minute,  which  involves  a  hard 
day's  work.  Recently  special  beating  machines  have  been  invented  which 
it  is  hoped  will  obviate  excessive  muscular  efforts,  exposure  to  intensive 
noises  and  accidents  from  hammer  blows. 

Leaf  metal  is  employed  in  the  manufacture  of  mouldings,  picture  frames, 
gilding  and  silvering  of  furniture,  art  goods,  etc.  The  leaf  metal  or  other 
gilding  materials  are  generally  applied  by  means  of  a  size  containing 
benzol  or  benzine,  acetone,  pyroxylin,  wood  alcohol,  amyl  acetate  and  am- 
monia. Apart  from  exposure  to  these  agents  and  leaf  metal  dust,  more  or 
less  white  lead  and  acetate  of  lead  are  used  in  this  industry  and  add  an  ele- 
ment of  danger.  The  work  is  generally  done  in  closed  rooms  to  avoid 
draughts  and  hence  the  air  is  charged  with  the  odors  of  glue,  varnish,  oil, 
turpentine,  shellac  and  the  other  agents  mentioned.     In  the  manufacture 


584        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

of  gold- threaded  textiles,  a  very  fine  metallic  dust^  is  evolved  which  has 
been  known  to  produce  catarrhal  conditions  of  the  eyes. 

According  to  Hirt,^  the  leaf-metal  workers  are  peculiarly  liable  to  diseases 
of  the  respiratory  organs  and  especially  to  tuberculosis. 

The  gold  leaf  workers  in  Vienna'^  have  a  very  high  morbidity  and  mortality 
from  chronic  bronchitis,  emphysema,  and  tuberculosis  of  the  lungs.  The 
morbidity  of  this  class  of  workers  in  Austria,  according  to  Jehle,^  is  42.5  per 
cent,  against  an  average  of  27.5  per  cent,  in  other  pursuits. 

The  vital  statistics  of  leaf  metal  workers  in  this  country  are  extremely 
meager.  Hoffman's  statistics  are  based  upon  25  deaths  from  all  causes;  of 
this  number  7  were  from  consumption  and  5  from  pneumonia  and  other 
diseases  of  the  lungs. 

Nickel. — This  metal  which  has  come  into  general  use  was  believed  to  be 
free  from  toxic  properties.  When  derived  from  arsenical  ore,  there  is 
danger  from  arsenical  fumes  during  the  roasting  operations.  Mond  in  1890 
discovered  that  by  passing  a  current  of  carbon  monoxide  over  finely  divided 
metallic  nickel,  a  gaseous  compound  of  nickel  and  CO  was  formed.  When 
heated  to  i5o°F.  the  gas  is  decomposed  into  its  constituents  and  metallic 
nickel  is  deposited. 

Nickel  carbonyl  (NiC04)  is  a  clear,  pale,  straw-colored  liquid  which  boils 
at  a  temperature  of  43°C.  This  salt  is  quite  volatile  and  a  peculiar  soot-like 
color  is  perceptible  when  present  in  the  air  to  the  extent  of  12,000,000  vols., 
while  a  Bunsen  flame  becomes  luminous  when  it  is  present  to  the  extent  of 
1,400,000  vols.  These  two  characteristics  are  relied  upon  to  detect  the  es- 
cape of  the  gas  during  the  manufacture  of  nickel  carbonyl,  which,  on  account 
of  its  toxic  properties,  must  be  carried  on  in  hermteically  closed  iron  chambers. 

The  process  was  introduced  in  the  beginning  of  the  present  century  and 
about  25  workmen  were  poisoned,  some  fatally,  before  the  danger  was  fully 
recognized.  In  the  milder  forms  of  poisoning  the  men  suffer  from  headache, 
giddiness,  unsteady  gait,  nausea  and  at  times  dyspnoea,  which  symptoms 
quickly  disappear  upon  removal  to  fresh  air.  In  the  more  severe  forms, 
the  dyspnoea,  after  a  lapse  of  12  to  36  hours,  is  increased,  accompanied  by 
cyanosis,  a  rise  in  temperature,  and  cough,  with  more  or  less  blood-stained 
expectoration.  The  action  of  the  heart  is  usually  found  to  be  increased,  but 
otherwise  normal.  Delirium  of  varying  types  is  generally  present.  Accord- 
ing to  H.  W.  Armit,^  the  fatal  cases  terminated  between  the  fourth  and 
eleventh  days.  Post-mortem  examination  revealed  hemorrhages  in  the  lungs, 
oedema  of  the  lungs,  and  hemorrhages  in  the  white  matter  of  the  brain.  Some 
doubt  exists  as  to  whether  any  blood  changes  were  present.  Oliver  states 
that  some  of  the  deaths  were  almost  instantaneous.  In  the  case  of  one  man 
who  died  after  3  days'  illness  the  lungs  were  found  to  be  oedematous  and  in- 
tensely congested.  In  another  case  there  was  inflammation  and  consolidation 
of  the  lungs.  In  the  third  case,  who  died  on  the  eighth  day,  numerous  hem- 
orrhages were  found  in  the  brain  and  cerebellum  and  the  nerve  cells  of  the 


THE    JEWELRY    AND    ALLIED    INDUSTRIES  585 

respiratory  nucleus  in  the  medulla  oblongata  showed  distinct  chromolytic 
changes.  For  some  years  it  was  believed  that  these  cases  were  instances  of 
carbon  monoxide  poisoning. 

Armit  experimented  upon  animals  to  determine:  (i)  whether  the  symp- 
toms and  lesions  observed  in  nickel  carbonyl  poisoning  were  caused  wholly 
or  in  part  by  the  CO  of  the  compound;  (2)  whether  nickel  carbonyl  is  ab- 
sorbed as  such;  and  (3)  whether  the  nickel  of  the  compound  is  the  toxic  factor. 
He  concluded  that  the  poisonous  effects  of  this  compound  are  due  to  nickel 
and  not  to  carbon  monoxide,  and  thinks  the  peculiar  toxicity  is  caused  by  a 
deposit  of  nickel,  as  a  slightly  soluble  compound  in  a  very  fine  state  of  sub- 
division, over  the  immense  area  of  the  respiratory  surface,  where  it  is  dis- 
solved by  the  tissue  fluids  and  is  then  taken  up  by  the  blood.  The  hemor- 
rhages found  after  death  are  in  his  opinion  caused  by  fatty  degeneration  of 
the  vessel  walls,  the  specific  pathological  change  having  been  set  up  by  the 
nickel. 

Iron  Carbonyl. — A  light  sherry-colored  Uquid  which  according  to  Oliver ^° 
is,  like  nickel  carbonyl,  extremely  volatile  and  equally  poisonous. 

Preventive  Measures. — As  cases  of  nickel  carbonyl  poisoning  occurred  only 
when  hand  labor  was  used,  during  a  breakdown  of  the  automatic  machinery, 
it  is  important  that  the  utmost  precautions  for  the  detection  and  removal  of 
the  gas  be  taken. 

Nickel  Plating. — -The  men  engaged  in  nickel  plating  not  infrequently 
develop  a  peculiar,  eczematous,  vesicular  inflammation  of  the  skin  affecting 
the  hands  and  arms  and  occasionally  also  other  portions  of  the  body.  The 
disease  is  attributed  by  some  authors  to  the  caustic  action  of  nickel  salts, 
especially  nickel  sulphate  or  nickel  cyanide,  employed  in  the  electrolytic 
bath.  Others  hold  that  such  agents  as  benzene,  petroleum,  soap,  and  lime, 
which  are  quite  generally  used  in  all  plating  processes,  are  responsible  for 
the  mischief,  while  still  others  maintain  that  it  is  the  result  of  a  combined 
action  of  various  irritants.  Whatever  the  exact  cause  may  be,  careful 
attention  to  the  skin,  in  the  way  of  cleanliness  and  the  application  of  vaseline 
or  cold  cream,  are  indicated  as  protective  measures. 

Surgeons  D.  E.  Robinson  and  J.  G.  Wilson^^  report  that  in  an  examination 
of  100  workers  in  the  manufacture  of  Jewelry  in  Cincinnati,  only  one  case  of 
tuberculosis  was  found. 

REFERENCES 

^  Koelsch. — Miinch.  med.  Wochenschrift,  January-February,  1912. 

2  Report  of  the  Mass.  State  Board  of  Health,  1909,  pages  25,53.     (See  also  report  on  sani- 
tary condition  of  factories  in  Mass.,  1907,  page  95.) 

'  Koelsch. — Soziale  Lage  u.  Krankheit,  Miinchen,  ist  Liefg.,  1912,  page  219. 

*  Baum. — Xeisser's  Internal.  Ubersicht  liber  Gewerbehygiene,  Berlin,  1907,  page  126. 

*Zadek. — Weyl's  Handbuch  der  Gewerbekrankheiten,  jena,  1908,  page  151. 

^  Walther. — Weyl's  Handbuch  der  Gewerbekrankheiten,  Jena,  1908,  page  663. 

^  Hirt. — Die  Krankheiten  der  Arbeiter,  1871,  I,  page  89. 

8  Jehle. — Zeitschft.  f.  Gewerbehygiene,  1895,  page  24. 

^  Armit,  H.  W. — Journal  of  Hygiene,  July,  1907. 
1"  Oliver,  T. — Diseases  of  Occupation  London,  1908,  page,  74. 
"  U.  S.  Public  Health  Bulletin  No.  73,  March,  1916. 


CHAPTER  IV 
IRON,  STEEL  AND  ALLIED  INDUSTRIES 

BY  GEORGE  M.  KOBER.  M.  D.,  Washington,  D.  C. 

Blast  Furnaces.  Bessemer  Steel  Works.  Electric  Welding.  Puddling.  Mechanica 
Departments.  Prevention  of  Accidents.  Foundries.  Core  and  Mould  Makers. 
Cleaning  and  ^Milling  Castings.  Blacksmiths,  Forgemen,  Boiler  Makers,  Riveters, 
Structural  Iron  Workers,  etc.  Cutlery  and  Tool  Industry.  Tempering.  File 
Cutting.  Gunsmiths,  Fire  Arms,  Weapons.  Agricultural  Implements.  Iron 
Sanitary  Ware  Factories.  Wire  Industry.- — Wire  Cloth,  Netting  and  Fencing 
Material.  Tin  Industry — Tin  Plating,  Tinners,  Tinsmiths.  Vanadium.  Pre- 
ventive Measures. 

Blast  Furnaces. — The  operation  of  reducing  iron  ore  in  a  blast  furnace 
is  necessarily  continuous  and  most  furnaces  operate  with  two  12-hour  shifts 
and  work  7  days  a  week.  During  the  year  1909,  of  the  total  number  of  wage 
earners  31,729,  or  82.6  per  cent.,  were  employed  in  establishments  where 
the  prevailing  hours  were  over  72  hours  a  week,  and  only  one-half  of  i  per 
cent,  worked  between  54  and  60  hours  per  week.  The  operatives,  apart 
from  hard  work,  are  exposed  to  excessive  heat,  abrupt  changes  in  tempera- 
ture, to  all  kinds  of  injuries,  burns  and  explosions,  more  or  less  dust  and 
sand  and  the  inhalation  of  toxic  gases  from  leaky  furnaces,  gas  valves  or 
mains  which  especially  endanger  the  men  while  engaged  in  cleaning  out 
the  furnaces  or  during  the  process  of  tapping  the  slag  or  the  metal.  The 
furnace  gases  contain  carbon  monoxide  and  dioxide  in  large  quantities, 
compounds  of  sulphur  and  cyanogen  and  even  lead  fumes,  if  lead  happens 
to  be  present  in  the  iron  ore.  In  granulating  the  slag  sulphureted  hydrogen 
is  also  evolved. 

Accident  Liability. — ^Of  19,604  blast-furnace  "300-day  workers"  reported 
for  the  year  ending  June  30,  1910,  by  the  U.  S.  Department  of  Labor,^ 
there  were  5047  accidents,  a  rate  of  257.4  per  1000;  of  these,  60  or  3.06  per 
cent,  proved  fatal;  50  or  2.55  per  cent,  resulted  in  permanent  and  4937 
in  temporary  disability. 

Preventive  Measures. — Great  care  should  be  taken  to  prevent  the  escape 
of  poisonous  gases  and  much  has  been  done  toward  their  utilization  for  heat, 
power  and  illuminating  purposes  in  the  steel  plants,  and  commendable  efforts 
are  being  made  in  safeguarding  the  operatives  against  accidents,  explosions, 
etc.,  by  the  construction  of  modern  strong  furnaces  with  water-cooling 
jackets  and  improved  methods  in  the  stoking  and  charging  of  the  various 
materials  and  in  the  tapping,  pouring  and  transportation  processes. 

586 


IRON,    STEEL    AND    ALLIED    INDUSTRIES 


587 


Bessemer  Steel  Works. — In  the  conversion  of  pig  iron  into  steel  by  the 
Bessemer  process,  apart  from  the  hard  work  and  exposure  to  intensive 
radiant  heat  and  escape  of  gases,  the  operatives  are  exposed  to  serious 
injuries  from  falling  scraps  from  above.  Burns  are  most  frequently  caused 
by  flying  sparks  of  "molten  metal"  from  the  converter  during  a  blow,  from 
spilling  of  the  hot  metal  ladles,  and  from  explosions  on  account  of  the  presence 
of  moisture  in  the  converter  or  from  the  normally  occluded  gases  of  the 
molten  metal. 


Fig.  37. — Welding  a  steel  ring  with  an  electric  arc.  The  workman's  eyes  are  protected 
from  the  lalinding  glare  by  three  panes  of  colored  glass  in  the  helmet,  which  also  defends 
his  face  and  neck  from  the  rays  that  destroy  the  skin.  (Photo  suppied  by  Wiirdemann, 
taken  from  The  World's  Work.) 

Electric  Welding. — In  the  electric  welding  of  steel,  etc.,  the  light  produced 
is  extremely  intense  (equal  to  about  8000  candle-power)  and,  as  the  operation 
has  to  be  closely  observed,  the  workmen  must  protect  their  eyesight  by 
shields  composed  of  six  alternating  layers  of  blue  and  red  glass.  The 
light  and  heat  evolved  are  sufficiently  intense  to  cause  a  condition  of  the  skin 
comparable  to  sunburn. 


588         ETIOLOGY    AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

Hirschberg-  describes  a  condition  of  the  eyes  in  persons  exposed  to  strong 
electric  light,  especially  in  the  electric  welding  of  steel  characterized  by 
lesions  of  the  conjunctiva,  cornea  and  retina  and  designated  by  him  as 
"electrical  ophthalmia."     Crzellitzer^  has  reported  similar  cases. 

Dr.  Apfelbach^  cites  50  cases  observed  by  him  among  workers  of  the 
Illinois  steel  plants,  caused  by  electric  light,  redundant  with  ultra-violet 
rays,  causing  conjunctivitis,  photophobia,  profuse  lacrymation,  temporary 
loss  of  vision,  and  rarely  keratitis,  retinitis,  permanent  pigment  changes  of 
the  retina  and  scotomata. 

Accident  LiahilUy. — Of  3668  300-day  workers  in  the  Bessemer  depart- 
ment of  steel  plants  reported  by  the  Bureau  of  Labor  there  were  1552  ac- 
cidents or  423.1  per  1000  with  16  deaths,  or  4.36  per  1000;  11  or  3  per 
1000  resulted  in  permanent  disability  and  1525  in  temporary  disability. 

Open-hearth  Steel  Works. — The  temperature  conditions  under  which 
the  men  work  during  particular  operations  have  been  studied  by  the 
Bureau  of  Labor. ^  In  spite  of  the  fact  that  all  doors  and  ports  were  water 
cooled  and  furnace  fronts  partly  cooled,  the  thermometer  6  or  7  ft.  in  front 
of  an  open  hearth  with  the  door  partly  open,  during  the  operation  of 
rabbling  the  bottom  and  stirring  heat,  registered  120°  and  155°;  at  a  dis- 
tance of  2  ft.,  and  while  banking  doors  with  dolomite,  the  workmen  were  ex- 
posed for  2  minutes  at  least  to  a  temperature  of  220°  and  over.  The  excessive 
heat  and  exposure  to  intense  light  in  the  various  processes  of  steel  making 
and  in  electric  welding  must  be  observed  in  order  to  be  fully  appreciated, 
and  naturally  calls  for  special  protection  of  the  eyes  by  means  of  suitable 
helmets  and  smoke-colored  glasses. 

Accident  Liability. — Of  9017  employees,  3067  were  injured — an  acci- 
dent rate  of  32.6  per  1000  with  30  deaths  {:i).2>i  per  1000);  38  or  4.21  per 
1000  resulted  in  permanent  and  2999  or  4.21  per  1000  resulted  in  temporary 
disability. 

Puddling. — The  process  of  puddling,  the  oldest  of  the  purifying  methods 
by  which  iron  is  produced,  is  carried  on  in  a  furnace  supplied  with  a  large 
fire-box  on  one  end,  the  flames  of  which  are  reflected  upon  the  pig  iron 
placed  in  an  adjacent  chamber.  When  the  mass  begins  to  liquefy,  the  puddler 
by  means  of  a  rabble  (a  hoe-shaped  iron)  stirs  the  molten  metal  and  as 
the  impurities  are  burned  out  the  melting  point  rises  and  the  metal  solidifies 
into  smaller  masses,  which  are  then  gathered  into  two  or  three  huge  balls. 
They  are  then  removed  and  hammered  or  squeezed  for  the  removal  of  slag. 
The  work  is  extremely  laborious  and  attended  by  exposure  to  intense  heat 
and  often  reckless  exposure  to  cold  draughts.  Apart  from  injuries  to  the 
eyes,  'those  exposed  to  the  intense  heat  and  light  are  liable  to  suffer  not  only 
from  chronic  conjunctivitis  but  also  from  more  serious  affections  of  the  eye. 
which  may  result  in  retinal  and  choroidal  lesions  and  also  in  cataract.  Dr. 
de  Schweinitz,  cited  by  Edsall,  states  that  he  could  often  tell  whether  iron 
puddlers  were  right  handed  or  left  handed  by  studying  the  effect  of  their  work 


IRON,    STEEL    AND    ALLIED    INDUSTRIES  589 

on  their  eye  grounds.  Quint  relates  cases  of  right-sided  cataracts  in  right- 
handed  iron  workers  and  cataracts  of  the  left  eye  in  those  who  were  left- 
handed.  It  is  very  likely  that  exposure  to  intense  heat  causes  dehydrization 
of  the  lense  and  other  pathological  conditions. 

Many  of  the  employees  have  intemperate  habits  and  as  a  result  of  com- 
bined influences  often  develop  diseases  of  the  respiratory  and  circulatory 
system  and  the  kidneys. 

Accident  Liability. — The  liability  of  puddlers  to  accidents  is  not  very 
great;  of  1239  w^orkers  investigated  by  the  Bureau  of  Labor  there 
were  62  injuries;  none  proved  fatal;  most  of  the  accidents  consisted  of 
minor  burns  and  sparks  flying  into  the  eyes  producing  only  temporary 
disabilities. 

Rolling  Mills. — In  this  department  the  men  are  likewise  exposed  to 
excessive  heat,  hard  work,  to  burns  from  flying  hot  metal  and  slag  and  the 
various  injuries  incident  to  the  moving  of  large  masses.  In  the  hand-operated 
mills  the  risks  from  burns  and  similar  injuries  incurred  in  handling  the  heated 
billets  and  managing  the  material  with  tongs  and  hooks  are  very  much 
greater  than  when  mechanical  means  are  employed;  on  the  other  hand,  the 
fatality  rates  and  permanent  injury  rates  are  greater  in  mechanical  mills, 
simply  because  if  a  man  is  caught  in  moving  machinery  a  severe  or  fatal 
injury  is  likely  to  result. 

Accident  Liability. — -In  13,566  workers  in  mechanically  operated  mills 
there  were  4199  accidents  or  309.5  per  1000;  of  these,  28  or  2.06  per  1000 
proved  fatal;  40  or  2.95  per  1000  resulted  in  permanent  and  4131  in  tem- 
porary disability.  Among  10,675  workers  in  "hand-operated  mills"  there 
were  3917  accidents  or  366.4  per  1000;  of  these  only  11  or  1.03  per  1000 
proved  fatal  and  28  or  2.62  per  1000  resulted  in  permanent  disability. 

Mechanical  Departments. — -AH  steel  plants  employ  a  large  number  of 
mechanics  covering  a  wide  range  of  occupations.  Those  engaged  in  repair 
work  are  liable  not  only  to  accidents  incident  to  their  own  occupation,  but 
also  those  occasioned  by  the  work  of  others,  such  as  unexpected  starting  of 
machinery;  leakage  of  gas  where  the  work  is  being  done  also  frequently  adds 
to  these  special  hazards. 

Accident- Liability. — Among  17,421  workers  reported  by  the  Bureau  of 
Labor  there  were  4147  accidents  or  238  per  1000;  of  these,  23  or  1.32  per 
1000  proved  fatal,  31  or  1.78  per  1000  resulted  in  permanent  injury  and  4093 
in  temporary  disability. 

Preventive  Measures.-— The  dangerous  machines  in  shops  are  the  saws, 
laths,  drills,  planers,  etc.,  and  it  is  extremely  gratifying  to  note  that  the  acci- 
dent rate  in  the  mechanical  department  of  one  of  our  large  steel  plants  has 
been  reduced  from  388  in  1905  to  114  in  1910  as  a  result  of  effective  safety 
devices. 

Yards. — Among  16,441  employees  in  steel  plant  yards  reported  upon  by 
the  Bureau  of  Labor  there  were  2483  accidents  or  151  per  1000;  of  these,  47 


590        ETIOLOGY   AND   PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

or  2.86  per  looo  proved  fatal  and  23  or  1.40  per  1000  resulted  in  permanent 
injury  and  2413  in  temporary  disability. 

Summary  of  Accidents. — The  investigation  by  the  Bureau  of  Labor,^  from 
the  report  of  which  the  foregoing  data  have  been  compiled,  covered  all  the 
accidents  which  occurred  during  the  year  ending  June  30,  1910,  in  155  steel 
plants  representing  a  working  force  of  158,604  employees,  equivalent  to 
146,979  300-day  workers.     The  general  accident  rate  was  245.2  per  1000; 


Fig.  38. — Hot  saw  in  beam  mill  thoroughly  guarded  to  prevent  sparks  from  flj'ing 
through  the  mill,  to  the  injury  of  the  workmen.  (Photo  supplied  by  Wlirdemann 
through  the  courtesy  of  Carnegie  Steel  Company.) 

the  fatality  rate  was  1.86;  the  rate  resulting  in  permanent  injury  was  2.72; 
and  the  rate  resulting  in  temporary  disability  of  i  day  or  over  was  240.6 
per  1000.  In  brief,  although  nearly  one-fourth  of  the  employees  met  with 
injuries,  only  1.9  per  cent,  of  all  the  accidents  resulted  fatally  or  in  per- 
manent injury. 

A  very  interesting  table  on  page  69  of  the  same  report,  covering  130  plants 
for  2  years,  ending  June  30,1910,  and  one  plant  for  6  years,  ending  December 
31,  19 10,  specifies  the  nature  of  the  disabling  injuries,  number  of  days  lost, 
etc.  Of  the  18,959  cases  thus  tabulated,  asphyxia  occurred  in  710  or  6 
per  cent,  of  the  cases;  fractures,  497  or  2.6  per  cent.;  dislocations,  555  or  2.9 
percent.;  injuries  to  the  eyes,  1056  or  5.6  per  cent.;  burns,  2842  or  15  percent.; 


IRON,    STEEL    AND    ALLIED    INDUSTRIES  59 1 

injuries  to  the  foot,  3306  or  17.4  per  cent.;  injuries  to  the  hand,  4908  or  25.9 
per  cent.;  injuries  to  other  parts, 3968  or  20.9  per  cent.; all  other  injuries,  17 16 
or  9  per  cent.  It  is  a  remarkable  fact  that  the  percentage  of  injuries  to  the 
eyes  according  to  the  Imperial  Insurance  Office  in  1897  was  about  the  same 
in  the  German  iron  and  steel  industry.  Two-thirds  of  the  eye  injuries  were 
caused  by  foreign  bodies  and  the  remainder  by  flying  sparks. 

The  report  emphasizes  the  fact  that  for  a  large  group  of  plants  in  which 
the  work  of  organized  accident  prevention  is  well  developed  the  accident 
rate  was  found  to  be  as  low  as  167  per  1000,  while  on  the  other  hand  in  groups 
of  plants  in  which  safety  work  has  not  yet  been  developed  it  was  as  high  "as 
506.9  per  1000,  and  in  some  of  the  individual  plants  in  this  group  considerably 
higher. 

According  to  Ropke,'^  during  1909  among  165,470  insured  employees  in 
the  "Rhein"  steel  plants  of  Germany  27,895  accidents  were  reported  or  169 
per  1000  workers;  of  these,  183  resulted  fatally,  198  in  total  and  i63oin  partial 
permanent  disability,  and  513  in  temporary  disability.  It  should  be  stated, 
however,  that  according  to  the  Report  of  the  Bureau  of  Labor  the  German 
accident  figures  include  no  temporary  disabilities  of  13  weeks  and  under. 
According  to  the  same  report,  more  than  half  of  the  accidents  during  a  6- 
year  period  in  one  of  the  American  Steel  plants  were  due  to  four  causes; 
viz.:  flying  and  falling  objects  25.2  per  cent.;  falls  of  the  worker  10.5  per  cent., 
hot  metal  explosions  and  spills  8.9  per  cent.;  and  the  operation  of  cranes  8 
per  cent. 

It  was  also  found  that  there  was  a  distinct  excess  in  the  number  of 
accidents  during  night  work  amounting  to  11.6  per  cent,  over  the  day  rates. 
The  data  in  reference  to  the  influence  of  long  hours  on  the  accident  rates 
were  not  sufiicient  to  justify  positive  conclusions,  but  appear  to  indicate  a 
tendency  to  greater  frequency  of  accidents  during  the  "long  turns."  A 
study  based  upon  26,839  accidents  shows  that  for  the  forenoon  of  the  10- 
hour  shift  the  greatest  number  of  accidents  occur  in  the  fourth  hour  and  for 
the  night  shift  during  the  second  and  third  hours  of  the  work.  This  is  con- 
trary to  the  general  expectation  that  accidents  increase  with  increasing 
fatigue  of  the  workers.  Several  reasons  for  this  contrast  are  suggested  in 
the  report,  viz.,  that  during  the  early  hours  of  the  night  turn  much  repair 
work  is  done  necessitating  overtime  work  of  the  day  mechanics,  hence  also  a 
larger  working  force  during  these  earlier  hours,  and  that  because  of  the 
fatigue  of  these  overtime  workers  and  a  tendency  to  hasten  their  work  in 
order  to  get  home  or  because  of  the  exigencies  of  the  case,  the  liability  to 
accidents  is  increased.  Another  and  quite  reasonable  explanation  offered 
by  the  superintendents  is  that  the  men  on  the  night  shifts  do  not  secure  the 
same  amount  of  restful  sleep  and  that  this  less  satisfactory  physical  condi- 
tion tends  to  bring  about  a  greater  number  of  accidents  during  the  period 
when  "they  are  getting  into  the  swing  of  the  work." 

A  study  of  the  seasonal  distribution  of  accidents  appears  to  justify  the 


592 


ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 


conclusion  that  both  extremes  of  heat  and  cold  have  an  influence,  the  heat 
condition  being  the  more  potent. 

Prevention  of  Accidents. — A  most  gratifying  reduction  in  the  number 
of  accidents  pecuUar  to  blast  furnaces  and  rolling  mills  has  been  accomplished 
since  1905  by  the  application  of  safety  devices.  The  rates  for  permanent  in- 
juries were  reduced  from  2.2  per  1000  in  1905  to  0.5  per  1000  in  1910; 
injuries  to  the  eyes  from  19.7  to  4.7;  bruising  injuries  to  the  hands  from 
58.7  to  27.2;  similar  injuries  to  the  feet  from  46.4  to  22.8;  bruises  to  other 


Fig.  39 — An  emery  wheel  equipped  with  heavy  steel  guard, 
belt  and  permanent  glass  guard  to  prevent  injury  to  the  eyes. 
Wiirdemann  by  the  U.  S.  Steel  Corporation.) 


Guard  on  pulley  and 
(Photo  furnished  to 


parts  of  the  body  from  72.6  to  26.6;  and  burns  from  hot  metal  from  16.5 
to  6.8  per  1000  workers.  A  chart  on  page  118  of  the  Government  Report^ 
shows  a  reduction  in  one  of  the  large  steel  plants  in  the  accident  rate  from 
370  in  1900  to  109  in  1910. 

Comparative  Morbidity  Rates.— We  know  that  the  morbidity  rates  are 
higher  in  the  large  steel  and  iron  plants  than  in  the  manufacture  of  ma- 
chinery and  other  mechanical  departments  of  this  industry.  So,  for  example, 
the  average  number  of  men  taken  sick  in  the  large  steel  plants  atSolingen 
in  1905  was  476  per  1000;  in  the  cutlery  industry  404;  and  in  the  sword, 
bicycle  industry,  etc.,  only  302  per  1000  (Ropke^). 


IRON,    STEEL    AND    ALLIED    INDUSTRIES 


593 


Hayhurst^"  gives  a  synopsis  of  the  chief  occupational  diseases  in  the  iron 
and  steel  industry  as  follows: 

1.  Heat  stroke  (apoplexy),  heat  exhaustion,  heat  cramps,  heat  anaemia 
and  heat  diarrhea,  premature  senility  in  older  employees. 

2.  Asthma,  bronchitis,  tuberculosis  and  hemorrhages  while  at  work,  due 
to  dust,  sand,  gas  and  fume  inhalations,  grinding  processes,  etc. 

3.  Gas  poisoning,  producing  chronic  symptoms  such  as  headaches, 
dizziness,  vomiting,  coated  tongue,  anaemia,  palpitation,  insomnia,  gen- 
eral debility,  mental  dullness,  and  later  depressive  insanity. 


■Jm^ 


Fig.  40. — Steel  dust  to  which  steel  workers  are  exposed.     Particles  magnified  40  diameters. 
(Photo  furnished  by  Hanson). 

4.  Conjunctivitis,  injected  or  bloodshot  eyes,  due  to  heat,  sand  and 
dust;  cataracts  among  those  exposed  to  white  heated  metals. 

5.  "  Sunburn"  of  arms,  hands,  and  face,  due  to  exposure  to  heated  metals. 
Small  hemorrhages  under  the  skin  of  the  face;  blistering,  foot  calluses, 
due  to  walking  over  hot  iron  plates,  etc.     Severe  callusing  of  the  hands. 

6.  Rheumatism  and  lumbago,  due  to  great  temperature  variations. 

7.  Heart  disease,  perhaps  evinced  by  sudden  deaths  while  at  work. 

8.  "Hammermans'  paralysis"  of  arms,  due  to  the  use  of  heavy  sledges, 
pneumatic  tampers  and  other  pneumatic  tools,  particularly  with  long 
strokes. 

38 


594 


ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 


9.  "Strikers'  arthritis"  of  wrist  and  elbows,  due  also  to  hammering  or 
holding  vibrating  tools. 

10.  Boiler-maker's  deafness.     Ferrosilicon  poisoning. 

The  U.  S.  census  for  1910  gives  the  percentage  of  the  chief  causes  of 
deaths  for  workers  in  this  industry  as  follows:  Tuberculosis  16.3;  accidents 
16.2;  pneumonia  10.8;  heart  disease  10;  Bright's  disease  6.6. 

The  morbidity  statistics  in  a  very  sanitary  steel  plant  employing  5602 
workers,  presented  by  Hayhurst  and  based  upon  the  records  of  a  sick  benefit 
association,  but  excluding  accidents  and  venereal  diseases,  show  that  there 
were  1444  claims  by  workers  sick  for  at  least  5  days,  or  an  annual  percentage 
of  7.2.  The  claims  for  systemic  diseases  were  as  follows:  Respiratory  391; 
digestive  285;  communicable  218;  musculo-osseous,  mostly  rheumatism  and 
lumbago,  184;  nervous,  mostly  neuralgia,  sciatica,  neurasthenia  and  neuritis, 
79 ;  skin  65 ;  circulatory  63 ;  urinary,  mostly  nephritis,  45 ;  strain,  mostly  hemor- 
rhoids, hernia,  and  heat  prostration,  41;  auto-intoxication  and  diabetes  27; 
chronic  infections  18;  special  senses  17;  lymphadenoids  and  neoplasm  11. 


Average  (Yearxy)  Morbidity  in  the  Various  Departments  of  an  Iron  and  Steel 
Establishment  During  a  Period  of  3  Years — 1911  to  1913  Inclusive 

(The  greatest  variation  of  numbers  employed  did   not   exceed  15   per  cent,  in  any  one 

department) 


Departments 


Average 
number  of 
employees 


Average 

number 

sick 


Average 

per  cent. 

sick 


(a)  Heat  exposed: 

Bessemer 

Open  hearth     

Rail  and  shape  mill  .  . 

Blast  furnaces 

Foundry 

Shelf  mills 

Pipe  mill 

{b)  Weather  exposed: 

Police 

Railroad  (yards) 

Section  hands 

Yard  labor 

Ore  docks 

Bricklayers 

Building  construction, 
(c)   Indoors  (mostly): 

Mechanical 

Electrical 

Miscellaneous 


Total 5619 


393-3 
145 -3 
500.0 
261 .0 
163.3 
348.3 
1764.7 

3S-0 
156.3 

IIO.O 

468.0 

90.3 

72.7 

106.3 

472.3 

181. 3 
351-6 


33 

0 

7 

0 

43 

3 

35 

0 

12 

7 

33 

3 

162 

0 

2 

7 

9 

0 

10 

0 

28 

7 

8 

3 

2 

7 

9 

7 

47 

7 

4 

3 

n 

3 

460 

7 

8.39 

4.81 

8.66 
13-41 
7-77 
956 
9.18 

7.62 
5-76 
9.09 
6.13 
9.19 
3-66 
9.07 

10.09 
2.37 
3-21 

8.20 


IRON,    STEEL   AXD    ALLIED   INDUSTRIES  595 

Foundries. — The  metal  is  reduced  to  a  molten  state  either  in  a  cupola,  by 
combustion  of  coke,  or  in  "open-hearth  furnaces"  heated  with  gas  flames; 
in  either  case  the  operations  involve  exposure  to  intense  heat  and  the  in- 
halation of  carbon  monoxide.  In  tapping  the  molten  metal  there  is  con- 
siderable danger  from  explosions  and  flying  sparks;  in  fact  most  of  the 
serious  burns  occur  in  tapping  either  the  slag  or  metal  or  during  the  trans- 
portation of  the  metal  to  the  moulds  and  the  process  of  pouring;  other 
injuries  are  contracted  in  the  moving  of  heavy  castings,  etc. 

Accidejit  Liability. — Among  16,480  foundry  employees  reported  upon 
by  the  Bureau  of  Labor^^  there  were  2198  accidents  or  133.4  per  1000 
workers.  Of  these,  8  proved  fatal,  37  resulted  in  permanent  disability  and 
2153  in  temporary  disability  of  i  day  or  over;  all  of  these  rates  are  much 
lower  than  in  the  other  departments  of  the  large  steel  plants;  injuries  of 
the  eyes  were  the  most  frequent  accidents,  next  came  bruises. 

Hayhurst's  Ohio  Survey ^^  supplies  statistics  for  1913  showing  that  the 
chief  causes  of  death  among  foundry  workers  are  pneumonia,  heart  disease, 
tuberculosis  and  violence.  Sick  benefits  were  distributed  as  follows:  Acci- 
dents and  burns  24. 2  per  cent. ;  rheumatism,  sciatica  and  neuritis  2 1 .8  per  cent. ; 
respiratory  diseases  16.7  per  cent.;  gastro-intestinal  diseases  10.4  per  cent.; 
heart,  kidney,  liver,  bladder  3.7  per  cent.;  tuberculosis  i.i  per  cent.,  and 
the  remainder  for  miscellaneous  diseases. 

Casters. — Apart  from  dust  inhalation  and  the  injurious  factors  already 
referred  to,  the  casters  are  also  exposed  to  organic  vapors  on  account  of 
the  material  of  the  cores,  which  are  made  by  mixing  sand  with  a  "  core  binder" 
such  as  flour,  sour  beer,  molasses,  starch  or  some  other  sticky  substance. 
The  cores  when  completed  are  covered  with  a  thin  layer  of  pulverized  coal 
or  graphite  which  forms  a  vitreous  layer  while  the  metal  is  being  poured. 
Contact  of  the  hot  metal  with  these  moist  moulds  naturally  causes  combustion 
of  the  organic  material  with  evolution  of  gases  and  steam. 

The  men  engaged  in  casting  generally  wear  smoked  glasses  to  protect 
their  eyes  from  the  brilliancy  of  the  light  and  sputtering  of  the  metal. 

Core  and  Mould  Makers. — These  employees  are  exposed  to  the  inhalation 
of  large  quantities  of  dust,  especially  in  sifting  the  sand  for  the  cores  and  in 
dusting  the  completed  moulds  with  powdered  charcoal  and  graphite. 

Female  labor  is  often  employed  in  the  making  of  cores  for  small  castings. 
The  men  engaged  in  breaking  up  the  hot  moulds  naturally  inhale  large 
quantities  of  dust. 

Ahrens^^  determined  the  presence  of  28  mg.  of  dust  per  cubic  meter  in  the 
air  of  the  foundry  room,  and  Hesse,^^  71.7  mg.  per  cubic  meter  in  the  air  of  the 
cleaning  and  polishing  room,  which  amount  according  to  his  calculation  would 
subject  each  operative  to  the  inhalation  of  42  grams  of  dust  per  annum. 

Apart  from  these  dangers,  foundries  are  notoriously  dirty  and  gloomy 
workshops  and  the  walls  and  windows  are  generally  covered  with  dust  and 
soot,  shutting  out  light;  very  few  are  properly  heated  and  in  winter  the  mould 


596        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

and  core  makers  who  work  in  wet  material  often  suffer  from  colds  which  are 
aggravated  by  drafts. 

It  is  by  no  means  infrequent  to  observe  red  hot  cast-iron  stoves  giving  off 
deadly  coal  gas  or,  what  is  even  worse,  open  wood  or  coke  fires,  provided  not 
so  much  for  the  comfort  of  the  workers  as  for  the  drying  out  of  the  moulds 
and  repaired  fire-clay  linings  for  the  "pouring  metal  pots." 


Fig.  41. — Machine  shop  workman  using  the  movable  burlap  screen  while  chipping  a 
piece  of  steel  at  bench  vice.  (Photo  furnished  Wiirdemann  by  the  U.  S.  Steel 
Corporation.) 

Cleaning  and  Milling  of  Castings.— In  the  removal  of  scales  dilute  sul- 
phuric acid  is  used,  the  fumes  of  which  are  irritating.  The  subsequent 
processes  of  smoothing  the  castings  by  means  of  sand  blasts,  tumbling  mills, 
emery  wheels,  etc.,  are  all  dust  producing  and  have  already  been  referred  to 
on  page  494. 

In  the  department  in  which  the  castings  are  sand-blasted  the  air  is  fre- 


IRON,    STEEL   AND    ALLIED    INDUSTRIES  597 

quently  impregnated  with  flying  sand  which  gets  into  the  eyes,  nose  and 
mouth  of  the  operatives,  the  effects  of  which  few  can  resist  for  any  length  of 
time;  most  of  the  men  have  to  quit  within  a  year  or  two.  Much  of  this  un- 
necessary suffering  is  now  prevented  by  thoughtful  employers  by  providing 
in  the  center  of  the  room  a  large  flaring  hood  with  upward  suction  draft,  the 
operatives  wearing  helmets  with  fine  wire  inserts  to  protect  the  eyes,  and  cloths 
underneath  the  helmet  for  the  protection  of  the  nose  and  mouth.  The  latest 
pattern  of  helmets  is  provided  with  a  tubing  through  which  fresh  air  is  sup- 
plied from  the  outside. 

Unfortunately  the  vital  statistics  of  foundry  workers  in  this  country  are 
extremely  defective.  The  Factory  Inspector  of  Massachusetts^^  made  a 
physical  examination  of  320  "moulders"  in  the  Fall  River  District  in  1910; 
of  these,  103  or  32.2  per  cent,  were  found  to  be  in  ill  health,  distributed  as 
follows:  Diseases  of  the  lungs  12.8  per  cent.;  valvular  diseases  or  dilatation  of 
the  heart  12.2  per  cent.;  diseases  of  the  kidneys  7.2  per  cent.  According  to 
Sommerfeld,^^  41.7  per  cent,  of  all  the  deaths  among  moulders  in  Germany 
are  caused  by  consumption  and  20.8  per  cent,  from  other  diseases  of  the 
lungs,  such  as  asthma,  bronchitis  and  emphysema.  The  consumption 
rate  for  casting  cleaners  was  35.7  per  cent,  and  for  other  diseases  of  the 
lungs  24.3  per  cent.  Apart  from  the  diseases  referred  to,  rheumatism, 
digestive  disorders,  affections  of  the  skin,  eyes  and  ears  are  also  quite 
common. 

Preventive  Measures. — There  can  be  no  question  that  the  factors  re- 
ferred to  render  employment  in  this  industry  more  or  less  injurious  to  health. 
It  should  be  remembered,  however,  that  bad  working  conditions  are  re- 
sponsible for  much  of  the  ill  health.  That  present  conditions  are  in  need  of 
and  susceptible  of  betterment  is  strikingly  evinced  by  the  following  com- 
ments of  medical  inspectors. ^^ 

"In  one  of  the  establishments  the  dust  from  the  polishing  and  buffing 
process  in  the  absence  of  hoods  and  exhaust  ventilation  was  very  great  and 
in  the  tumbling  room  was  so  thick  that  objects  a  few  feet  distant  cannot 
clearly  be  made  out.  Many  men  refuse  to  work  in  this  establishment  on 
account  of  the  excessive  heat  and  general  discomfort." 

In  another  establishment  the  general  surroundings  were  extremely  favor- 
able, the  room  in  which  the  castings  were  cleaned  and  tumbled  was  large  and 
airy;  in  the  polishing  room  the  emery  wheels  were  provided  with  hoods  and 
exhaust  ventilation,  but  the  men  ignorant  of  the  dangers  habitually  removed 
the  hoods,  maintaining  that  the  hoods  interfere  with  their  work  and  that 
"iron  dust  is  strengthening  as  it  enriches  the  blood." 

It  is  gratifying  to  note  that  thoughtful  foundry  owners^^  appreciate  that 
health  and  efficiency  can  be  promoted  by  providing  suitable  workrooms, 
properly  heated  and  equipped  with  mechanical  devices  for  the  removal  of 
dust,  gases  and  fumes;  they  also  furnish  pure  drinking  water  and  good 
washing  and  bathing  facilities.     All  others  should  be  required  to  do  like- 


598        ETIOLOGY   AND   PROPHYLAXIS   OF   OCCUPATIONAL  DISEASES 

wise,  and  when  thus  provided  the  workmen  should  be  obliged  to  avail 
themselves  of  these  safeguards. 

Blacksmiths,  Forgemen,  Boilermakers, Riveters,  Structural  Iron  Workers, 
Etc. — Space  will  not  permit  a  consideration  of  all  the  occupations  connected 
with  the  iron  industry,  and  hence  only  a  few  of  the  more  hazardous  trades 
can  be  considered. 

Blacksmiths  and  forgemen,  apart  from  hard  work  and  exposure  to  in- 
tense heat  and  abrupt  changes  in  temperature,  are  also  exposed  to  the 
inhalation  of  coal  dust,  smoke,  fuel  gases  and  the  fumes  evolved  during  the 
tempering  and  case  hardening  with  lead,  potassium  cyanide  and  oil.  There 
is  also  danger  from  flying  scales  which  not  infrequently  affect  the  eyes. 

Wounds,  contusions,  burns,  fractures  and  hernia  are  not  infrequent. 
They  are  also  liable  to  conjunctivitis  and  skin  affections  caused  by  exposure 
to  radiant  heat  and  deposits  of  dust.  Lumbago  and  acute  rheumatism 
are  frequently  met  with.  According  to  Sommerfeld^^  66.6  per  cent,  of  all 
the  deaths  in  this  class  of  workmen  are  caused  by  consumption  and  8.4 
per  cent,  by  other  diseases  of  the  lungs. 

The  tuberculosis  death  rate,  while  very  high  in  Germany,  is  not  excessive 
in  this  country.  According  to  U.  S.  census,  11.4  per  cent,  of  blacksmiths 
died  of  pulmonary  consumption,  8  per  cent,  of  pneumonia,  13.8  per  cent,  of 
heart  disease,  10  per  cent,  of  apoplexy  and  9.7  per  cent,  of  Bright's  disease. 

Hypertrophy  of  the  heart,  diseases  of  the  aortic  valves  and  of  the  kidneys 
are  not  uncommon.  When  most  of  the  heavy  work  was  done  by  manual 
labor  instead  of  machinery,  rupture  of  muscular  fibers  of  the  upper  arm  and 
shoulder  and  cases  of  so-called  "hammer's  paralysis"  caused  by  overfatigue 
of  the  muscles  of  the  arm  were  frequently  met  with.  Even  now  occasional 
cases  may  be  observed  in  forgemen,  and  likewise  instances  of  "strikers' 
arthritis"  which  is  a  painful  inflammation  of  the  wrist-  and  elbow-joints. 

The  men  engaged  in  handling  sledge  hammers,  chisels,  files  and  other 
tools  are  also  liable  to  develop  disagreeable  callosities  and  thickening  of 
the  fascia  with  consequent  contraction  of  the  fingers  toward  the  palm  of 
the  hand;  Faulty  positions,  stooping  over  anvils,  work  benches,  etc.,  are 
a  frequent  cause  of  lateral  spinal  curvature  and  of  genu  valgum  ("knock- 
knee")  in  youthful  workers  and  should  be  prevented  by  teaching  apprentices 
at  the  outset  correct  positions. 

The  work  of  boiler  makers  and  structural  iron  workers  is  also  laborious 
and  attended  with  more  or  less  danger  from  accidents.  As  a  result  of  hard 
work  and  exposure  to  abrupt  changes  in  temperature  they  are  liable  to  the 
development  of  rheumatic,  neuralgic  and  catarrhal  affections  and  diseases 
of  the  respiratory  and  circulatory  organs.  In  riveters  using  a  hand  hammer 
spasm  and  paralysis  of  the  muscles  of  the  hands  are  liable  to  occur,  while  the 
constant  jarring  of  the  automatic  hammer  has  been  known  to  produce  occupa- 
tional neuroses.  Progressive  impariment  of  hearing  is  by  no  means  confined 
to  boiler  makers  and  riveters  since  Gottstein  and  Kayser^**  found  that  fully 


moN,  STEEL  A^^)  allied  industries  599 

6i  per  cent,  of  the  blacksmiths  and  locksmiths  examined  suffered  from  partial 
deafness. 

The  Cutlery  and  Tool  Industry.— This  extensive  industry  involves  a 
number  of  processes,  such  as  iron  and  brass  founding,  forging,  blacksmith- 
ing,  welding,  tempering,  grinding,  poUshing,  buffing,  pickHng,  acid  dipping, 
enameling,  etching,  electroplating,  tinning,  wood  working,  painting,  varn- 
ishing, etc.  The  health  hazards  are  peculiar  to  the  different  processes 
named. 


Fig.  42. — Grinding  iron  castings.     Employee  is  wearing  goggles  to  prevent  injury  to  his 
eyes.     (Photo  taken  by  Hanson  for  the  Mass.  State  Board  of  Health.) 

Steel  Grinding  and  Polishing. — In  the  grinding  and  polishing  processes 
of  the  metal  industry  in  general,  and  in  the  manufacture  of  cutlery,  tools 
and  steel  implements  in  particular,  immense  quantities  of  dust  are  evolved, 
not  only  from  the  metallic  surfaces  but  also  from  the  numerous  grind- 
stones, revolving  wire  brushs,  emery  and  corundum  wheels  and  other  buffing 
material.  Professor  Roth"^  estimates  that  a  grindstone  2  meters  in  diameter 
and  10  cm.  in  width  after  4  months'  constant  use  is  reduced  fuUy  one-half, 
and  the  various  metal  implements  lose  from  20  to  30  per  cent,  of  their  original 


600        ETIOLOGY    AND    PROPHYL.\XIS    OF    OCCUPATIONAL    DISEASES 

weight  during  the  grinding  process.  This  affords  an  approximate  idea  of 
the  amount  of  dust  production,  which  is  not  always  wholly  avoidable,  even 
by  the  employment  of  hoods  and  exhaust  ventilation  or  by  the  wet  process, 
especially  during  the  "racing"  of  the  grindstones. 

It  is  well  known  that  the  inhalation  of  the  hard  sharp  and  angular  particles 
of  steel,  sand,  an  emery  dust  produce  a  very  intensive  irritation  of  the 
mucous  membranes  of  the  nose  and  air  passages,  causing  not  only  catarrhal 
conditions,  but  also  more  serious  chronic  inflammations  of  the  respiratory 
organs,  such  as  bronchitis,  peri-bronchitis,  fibroid  pneumonia,  also  spoken  of 
by  the  workmen  as  "grinders'  asthma"  and  "grinders'  rot."  The  chronic 
inflammatory  conditions  thus  produced,  together  with  exposure  to  dampness 
and  other  injurious  factors,  naturally  favor  infection  with  the  tubercle 
bacillus. 

Hirt  gives  the  percentage  of  consumption  in  the  total  number  of  sick 
among  different  classes  of  metal  workers  as  follows:  Needle  polishers  69.6 
per  cent.;  file  cutters  who  are  also  exposed  to  lead  poisoning  62.2  per  cent.; 
grinders  40  per  cent.;  and  nail  cutters  12  per  cent. 

Beyer^^  found  that  of  196  needle  polishers  at  Remsheid  only  24  were  over 
40  years  of  age.  The  reason  why  this  occupation  is  especially  dangerous  is 
because  the  "wet  process"  cannot  be  employed  for  small  objects,  which  more- 
over have  to  be  brought  more  closely  to  the  eyes,  and  thus  the  chances  for 
the  inhalation  of  dust  is  increased. 

Hoffman^^  reports  that  of  128  deaths  among  grinders  63  or  49.2  per  cent, 
were  due  to  industrial  tuberculosis  as  compared  with  14.8  per  cent,  in  the  total 
male  population  over  15  years  of  age  in  the  U.  S.;  15  deaths  were  caused  by 
pneumonia;  5  by  asthma  and  bronchitis,  and  2  by  other  diseases  of  the 
respiratory  organs,  a  total  of  85  deaths  or  66.4  per  cent,  from  diseases  of  the 
lungs. 

The  death  returns  for  12  years  of  the  city  of  Northampton,  Mass.,^* 
one  of  the  centers  of  the  cutlery  and  tool  industry,  show  that  among 
"grinders,"  "polishers,"  and  "cutlers"  diseases  of  the  lungs  were  responsible 
for  72.73  per  cent,  of  the  mortality,  inclusive  of  54.5  per  cent,  of  deaths  from 
tuberculosis. 

During  1 850-1874,  according  to  Oldendorff  quoted  by  Ropke,^^  the 
mortality  among  the  grinders  and  polishers  over  20  years  of  age  of  Solingen, 
the  seat  of  the  cutlery  industry  in  Germany,  was  25  per  1000,  as  compared 
with  12.6  in  the  general  male  population.  From  1885-1895  the  relative  figures 
were  20.63  P^r  1000  among  the  grinders  and  polishers  and  13.6  in  the  general 
male  population  over  20  years  of  age. 

According  to  Dr.  Scurfield,  Medical  Officer  of  Health  of  Sheffield  in 
England,  the  mortality  rate  of  the  steel  grinders  over  18  years  of  age  between 
1 901-1909  was  30.4  per  1000  and  in  the  male  population  over  20  years 
of  age  only  16.4  per  1000;  the  tuberculosis  death  rate  was  15.1  and  from  other 
diseases  of  the  lungs  5.4.     Most  commendable  progress  has  been  made 


IRON,    STEEL    AXD    ALLIED    INDUSTRIES  6oi 

at  Solingen,  where  according  to  Ropke  the  mortality  has  been  reduced  from 
20.63  in  1885  to  9.3  per  1000  in  1910  and  the  mortality  from  diseases  of  the 
respiratory  organs  from  12.82  in  1885  to  6.72  per  1000. 

In  addition  to  the  dangers  i*eferred  to,  the  "grinders"  not  infrequently 
sustain  injuries  from  bursting  grinding  stones  and  polishing  wheels  while 
in  motion,  for  which  adequate  protection  has  been  found  in  the  case  of  the 
smaller  wheels  by  a  strong  hood  which  incloses  the  wheel  except  at  the  point 
where  the  grinding  is  done,  while  for  the  larger  wheels  a  special  form  of  wheel 
with  a  safety  collar  is  used. 

The  "wet  process"  is  not  by  any  means  free  from  danger.  While  dust 
production  is  reduced  to  a  minimum,  the  constant  throwing  oflf  of  water 
saturates  the  clothing,  floors  and  air  and  predisposes  to  "colds"  and  rheu- 
matic conditions,  especially  when  the  operatives  are  careless  about  their 
clothing. 

Some  of  the  grinders  also  assume  a  faulty  position,  crouching  over  their 
work,  which  interferes  with  the  free  expansion  of  the  lungs. 

Preventive  Measures. — Apart  from  securing  general  sanitary  working 
conditions,  every  effort  must  be  made  to  diminish  the  amount  of  dust  produc- 
tion to  a  minimum  by  substitution  of  the  "wet  process"  as  far  as  practicable. 
In  Solingen  the  "dry  grinders"  furnish  13.7  per  cent,  of  the  lung  diseases,  the 
"wet  grinders"  11. 3  per  cent.  In  all  "dry  grinding  processes"  forced  ven- 
tilationby  means  of  hoods  connected  with  a  system  of  exhaust  fans  or  blowers 
to  carry  away  the  dust  from  the  operator  should  be  installed  and  their  faithful 
use  insisted  upon. 

Unfortunately,  in  this  country  at  least,  a  large  proportion  of  grinders, 
prefering  freedom  of  movement,  remove  the  hoods  and  thus  expose  them- 
selves unnecessarily  to  this  especially  dangerous  form  of  dust.  This  state  of 
affairs  can  be  overcome  only  by  general  education  and  legislation.  Scrupu- 
lous cleanliness  of  the  person,  clothing,  tools  and  work  benches  should  be 
observed.  The  employees  should  be  taught  from  the  outset  proper  positions 
and  the  habit  of  breathing  through  the  nose.  Abnormal  conditions  such  as 
adenoids,  enlarged  tonsils,  etc.,  necessitating  mouth  breathing,  should 
be  removed. 

The  results  of  ameliorating  efforts  are  strikingly  shown  not  only  by  the 
decreased  mortality  rates  at  Solingen,  but  also  by  the  fact  that  morbidity  and 
loss  of  work  among  the  insured  grinders  has  been  reduced  from  38.5  per  cent, 
in  1886-1898  to  22.6  per  cent,  in  1902-1904.  Grindstones  should  be  in- 
spected in  order  to  detect  flaws,  properly  mounted  and  secured  by  means 
of  plates  and  bolts  and  the  safety  devices  already  referred  to.  For  genera) 
and  individual  hygienic  measures  see  also  pages  428,  429. 

Tempering. — The  process  of  tempering  or  hardening  of  metals  is  carried 
on  very  extensively  in  the  metal  industry,  especially  in  the  manufacture  of 
cutlery  and  tools,  springs,  files,  foundry  and  machine-shop  products,  auto- 
mobile and  bicycle  parts,  sewing  machines,  stamps  and  stencils,  cash  registers, 


6o2        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

electric  apparatus,  etc.  This  process  is  not  dangerous  to  health  when  it 
involves  simply  heating  and  cooling,  or  heating  and  dipping  into  water  or 
brine.  On  the  other  hand,  the  dipping  into  hot  bed  of  lead,  oil,  or  potassium 
cyanide,  or  the  application  of  potassium  cyanide,  and  subsequent  heating  in 
an  oven,  involve  serious  risks  unless  done  with  special  precautions  and  ade- 
quate exhaust  ventilation.  A  patented  preparation  advertised  recently 
as  a  harmless  substitute  for  "case  hardening"  is  said  to  yield  the  poisonous 
cyanide  radical  when  melted  for  use. 

File  Cutting. — It  is  to  be  regretted  that  machine  work  has  not  wholly 
supplanted  the  dangerous  process  of  hand  file  cutting.  It  is  claimed  that 
the  best  files  are  cut  by  hand,  and  as  long  as  there  is  a  demand,  manufacturers 
will  continue  to  supply  it  regardless  of  the  health  of  the  workers.  This  occu- 
pation appears  to  be  the  most  dangerous  of  all  dusty  occupations;  the  com- 
parative mortality  rate  in  England  is  given  by  Dr.  Tatham^'^  as  1810,  prac- 
tically three  times  higher  than  that  of  agriculturists.  This  excessive  mortality 
is  due  to  a  combination  of  causes,  viz.:  i.  The  laborious  character  of  the 
work  incident  to  the  use  of  the  steel  hammer,  which  weighs  from  8  to  20  lb., 
and  during  an  average  day's  work  amounts  to  lifting  over  150,000  lb.  weight. 
2.  The  work  is  performed  in  a  stooping  position,  which  interferes  with 
normal  respiration.  3.  Both  the  smoothing  process  of  the  blank  files  and 
the  process  of  cutting  the  lines  by  means  of  a  chisel  and  hammer  involves  the 
inhalation  of  steel  dust.  4.  While  the  file  is  being  cut  it  is  usually  held 
upon  a  leaden  bed  to  prevent  slipping  and  a  sharp  recoil  and  also  to  protect 
the  already  cut  surface  from  injury.  During  this  process  particles  of  lead 
may  be  inhaled  or  swallowed  with  the  dust,  or  they  may  be  taken  up  by  the 
fingers  in  brushing  off  the  file,  or  in  handling  the  bed,  and  carried  to  the 
mouth  in  licking  the  fingers  and  left  thumb  to  secure  a  firmer  grip  of  the 
chisel.  Another  source  of  lead  poisoning  is  that  the  files  are  hardened 
by  passing  them  through  kettles  of  molten  lead.  From  3  to  6  per  cent,  of  lead 
have  been  revealed  in  the  dust  of  file-hardening  establishments. 

The  Ohio  Survey  of  1914  dislcosed  cases  of  lead  poisoning,  occupation 
neurosis  from  hammering,  rheumatism,  stiff  wrists,  diseased  gums  and  teeth, 
and  inflammation  of  the  margin  of  the  eyelids. 

According  to  Sprenger,  cited  by  Ropke,  5.24  per  cent,  of  the  file  cutters  in 
Berlin  using  the  lead  bed  suffer  annually  from  plumbism. 

Preventive  Measures. — Efficient  exhaust  ventilation  and  adjustable  seats 
and  work  benches  are  indicated.  All  sorts  of  substitutes  for  the  lead  beds, 
such  as  pads  of  paper,  wood,  clay,  sand,  gutta  percha,  etc.,  have  been 
tried  and  finally  block  tin  has  come  into  use,  which  Ropke  declares  to  be 
free  from  objections  both  from  the  hygienic  as  well  as  technical  point  of  view. 

Gunsmiths,  Firearms,  Weapons. — The  mortality  figure  of  gunsmiths  ac- 
cording to  Tatham  is  1228,  or  100  in  excess  of  that  of  metal  workers  in  the 
aggregate;  the  mortality  from  phthisis  is  324  as  compared  with  206  among 
other  metal  workers,  and  185  for  all  other  occupied  males;  the  death  rate 


IRON,    STEEL    AND    ALLIED    IXDUSTRIES  603 

from  other  diseases  of  the  lungs  and  the  heart  is  also  excessive.  Tatham  re- 
gards most  of  the  processes  in  which  they  are  engaged  as  injurious,  especially 
the  exposure  to  the  inhalation  of  metallic  and  mineral  dust  during  the  filing 
and  polishing  of  the  metal.  The  occupation  is  often  carried  on  in  insanitary 
shops,  and  the  employees  in  England,  otherwise  high-grade  men,  appear  to 
suffer  from  the  alcohol  habit. 

The  men  employed  in  the  manufacture  oi  firearms,  in  the  metal  depart- 
ment, apart  from  the  inhalation  of  metalHc  dust,  not  infrequently  are  exposed 
to  nitrous  gases  evolved  in  the  etching  process,  to  vapors  of  antimony  com- 
pounds in  the  burnishing  of  rifle  barrels,  and  in  the  steel  bluing  room  to  the 
fumes  of  charcoal,  giving  off  carbon  monoxide.  In  the  manufacture  of  gun 
stocks,  large  quantities  of  fine  black  walnut  dust  is  evolved. 

In  the  manufacture  of  swords,  sabers,  bayonets,  etc.,  apart  from  the 
dangers  incident  to  steel  grinding  and  polishing,  the  men  engaged  in  firfe 
gilding  are  exposed  to  the  risk  of  mercurial  poisoning. 

Agricultural  Implements. — Automobiles,  motorcycles,  bicycles,  sewing 
machines,  cash  registers.  In  the  manufacture  of  these  goods  various 
processes  are  involved;  some  are  characteristic  of  the  metal  industry,  such 
as  brass  and  iron  founding,  blacksmithing  and  forging,  welding,  bronzing, 
tempering,  grinding,  polishing,  buffing  and  dipping,  electroplating,  etc. 
There  may  also  be  more  or  less  woodworking  and  painting,  with  all  of  the 
hazards  attending  these  operations. 

Iron  Sanitary  Ware  Factories. — The  dangers  to  the  workers  employed  in 
the  manufacture  of  so-called  porcelain  or  vitreous  enameled  iron  ware,  such 
as  bath  tubs,  sinks,  basins,  gas  stoves,  hollow  ware,  iron  plates  for  sign 
boards,  etc.,  are  the  elements  of  overfatigue,  excessive  heat,  and  exposure 
to  dust  containing  poisonous  lead  compounds.  This  industry,  as  conducted 
at  present  in  this  country,  must  be  regarded  as  extremely  dangerous.  In 
Germany  the  enamel  employed  is  leadless,  while  in  this  country  it  contains 
from  23^^  to  25  per  cent,  of  lead.     (See  also  page  in.) 

The  Wire  Industry. — When  the  ingots  are  ready  in  the  "open-hearth 
department "  of  \sdre  mills  they  are  rolled  into  long  rods  and  placed  upon  large 
spools  or  reels,  from  which  the  rod  is  carried  through  the  drawing  block  and 
thence  to  another  revolving  drum  drawing  the  rod  through  the  block.  This 
process  is  repeated  until  the  desired  size  of  the  wire  is  reached.  The  work- 
men are  protected  to  a  certain  extent  from  the  heat  by  metallic  screens 
over  which  water  trickles,  but  cases  of  heat  exhaustion  are  not  uncommon, 
especially  in  summer.  The  process  is  quite  dusty  from  the  lime  which  is 
put  on  the  wire  to  prevent  rusting.  The  occupation  also  involves  consider- 
able liabiUty  to  accidents  as  a  result  of  the  fingers  getting  caught  between 
the  wire  and  the  drum  in  drawing  from  the  block.  It  not  infrequently 
happens  that  in  passing  to  the  block  the  moving  wire  becomes  tangled  and 
the  operator  is  caught  and  drawn  toward  the  block.  Unless  the  machine 
can  be  stopped  the  workman  is  likely  to  be  seriously  injured,  the  loss  of  a 


6o4        ETIOLOGY   AND   PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

hand  or  a  foot  being  often  recorded.  To  guard  against  this  possibility  an 
automatic  stop  has  recently  been  introduced  and  proved  to  be  an  effective 
safeguard.^^ 

After  the  wire  is  hardened  by  being  run  through  crude  oil  it  is  passed 
through  kettles  of  molten  lead  inside  the  tempering  furnaces,  and  the  men 
who  feed  and  tend  the  furnaces  not  infrequently  sufifer  from  chronic  lead 
poisoning,  a  danger  wholly  avoidable  by  efficient  mechanical  ventilation, 
which  would  carry  these  fumes  to  the  outer  air. 

Other  sources  of  danger  in  the  manufacture  of  wire  are  the  employment  of 
sulphuric  acid  for  annealing  and  pickling  purposes,  the  coppering  process  by 
the  employment  of  sulphate  of  copper.  The  dangers  from  carbon  disulphide 
and  lead  incident  to  the  manufacture  of  insulated  wire  and  cable  should 
also  be  mentioned. 

*  In  the  process  of  galvanizing  wire  it  is  first  passed  through  diluted  com- 
mercial sulphuric  acid,  next  through  a  weak  solution  of  hydrochloric  acid 
and  finally  through  molten  zinc  (see  page  502). 

Preventive  Measures. — It  is  needless  to  insist  that  adequate  provisions 
should  be  made  to  carry  off  the  acid  and  metal  fumes  rapidly  into  the  outer 
air.  The  workmen  should  be  instructed  to  avoid  the  fumes  as  much  as 
possible  and  to  annoint  the  lips  and  nose  within  and  without  several  times  a 
day  with  lanolin. 

Wire  Cloth,  Netting  and  Fencing  Material. — In  the  manufacture  of  these 
materials  the  wire  is  first  rolled  on  spools  and  drums  to  form  the  warp  and  is 
then  woven  by  means  of  heavy  looms.  There  is  no  special  danger  in  this 
industry  unless  the  japanning  is  done  without  adequate  exhaust  ventilation. 
The  latter  process  is  usually  carried  on  in  a  suitable  tower,  the  cloth  passing 
from  the  rolls  through  a  vat  of  japan,  and  as  it  emerges  is  subjected  to  the 
action  of  a  blower,  then  passing  upward  through  several  stories,  where  it  is 
dried  by  steam  heat,  and  finally  descending  on  another  side  to  be  wound  again 
into  rolls. ^° 

Tin  Industry,  Tin  Mining. — Dr.  Ogle,  the  Registrar  General  of  Great 
Britain,  was  perhaps  the  first  to  point  out  that  the  consumption  rate  among 
the  Cornish  tin  miners  was  far  in  excess  of  any  other  class  of  miners;  other 
diseases  of  the  lungs  are  also  more  common.  Consumption  is  the  cause  of 
29.9  per  cent,  of  all  the  deaths,  bronchitis  13.5  per  cent.;  pneumonia  and  other 
diseases  of  the  lungs  contribute  12.5  per  cent,  of  the  mortality.  The  death 
rate  in  1904  in  miners  between  25-45  years  was  eight  to  ten  times  higher 
than  among  coal  and  iron-ore  miners  of  the  same  age.  The  increased  mor- 
tality in  recent  years  is  attributed  by  Oliver  to  the  increasing  employment 
of  rock  drills,  and  to  the  fact  that  a  good  many  men  have  worked  previously 
in  the  quartz  mines  of  the  Transvaal. 

Since  tin  is  not  regarded  as  a  toxic  metal  like  lead,  the  undue  prevalence 
of  diseases  of  the  respiratory  organs  has  generally  been  attributed  to  the 
inhalation  of  the  hard,  sharp  and  angular  particles  of  dust. 


IRON,    STEEL    AND    ALLIED    INDUSTRIES  605 

Cases  of  tin  poisoning  have  been  reported,  but  it  has  never  been  satis- 
factorily shown  that  tin  was  the  real  cause  of  the  intoxication.  On  account 
of  the  widespread  use  of  tin,  especially  in  connection  with  the  canning 
industry,  Dr.  Salant^^  of  the  U.  S.  Dept.  of  Agriculture  has  recently  under- 
taken an  investigation  as  to  the  behavior  of  tin  in  the  body.  Animal 
experimentation  has  shown  that  absorption  of  tin  from  the  gastro-intestinal 
canal  is  not  only  possible,  but  that  repeated  ingestion  of  the  salts  of  tin 
produces  changes  in  the  alimentary  mucosa  which  favor  the  absorption  of 
tin.  Animals  which  had  received  daily  doses  of  sodium  stannous  tartrate 
showed  no  tin  in  the  urine  until  after  the  first  week.  When  tin  was  introduced 
into  the  circulation,  the  gastro-intestinal  tract  appeared  to  be  the  chief  organ 
for  its  elimination.  The  tin  disappears  from  the  blood  in  2  or  3  hours  after 
an  intravenous  injection  of  its  salts,  and  can  be  found  in  the  liver,  brain  and 
muscles,  showing  conclusively  that  when  it  actually  reaches  the  circulation 
its  distribution  becomes  very  general.  It  is  hoped  that  these  experiments 
will  be  continued,  in  order  to  clear  up  the  toxicologic  problem  of  tin. 

Tin  containing  about  10  percent,  of  lead  was  atone  time  quite  extensively 
used  for  the  manufacture  of  trophy  cups,  coffee  and  tea  pots,  plates,  spoons, 
art  goods,  toys,  etc.  The  use  of  pewter,  German  silver  and  Britania  metal 
has  to  a  considerable  extent  displaced  the  manufacture  of  the  former  tin 
ware.  The  dangers  in  the  industry  are  incident  to  the  polishing  processes 
and  also  from  lead  poisoning,  which  is  proportioned  to  the  amount  of  lead 
used. 

Tin  plating  on  iron  or  steel  sheets  has  become  a  large  and  still  growing 
industry,  in  which  more  or  less  female  and  youthful  laborers  find  employment. 
The  material  is  used  for  roofing  purposes,  the  manufacture  of  tin  cans,  boxes, 
hollow  ware,  patent  bottle  caps,  etc.  Culinary  and  domestic  utensils  like 
saucepans  and  iron  kettles  are  also  tinned.  The  general  process  of  tin 
plating  is  similar  to  the  galvanizing  with  zinc,  except  that  the  metal  requires 
more  careful  cleaning  and  smoothing  of  its  surfaces.  The  pickling  with  a 
weak  solution  of  sulphuric  acid  is  followed  by  dipping  into  a  solution  of  weak 
hydrochloric  acid  and  zinc  chloride.  The  metal  is  then  dipped  into  a  bath 
of  molten  tin,  but  very  often  the  percentage  of  lead  exceeds  that  of  the  tin, 
and  hence  the  operatives  in  addition  to  the  exposure  to  acid  and  zinc 
fumes  incur  the  risk  of  lead  poisoning. 

OHver^-  points  out  that  the  cheaper  ware  is  frequently  dipped  in  a  com- 
position of  70  per  cent,  of  lead  and  30  per  cent,  of  tin,  thus  exposing  not  only 
the  workers  but  also  the  purchaser  of  such  utensils  to  the  danger  of  lead 
poisoning.  A  number  of  cases  of  lead  poisoning  have  likewise  been  reported 
in  consumers  of  canned  foods,  especially  of  acid  fruit,  and  even  carpenters 
and  shoemakers  have  contracted  lead  poisoning  from  holding  so-called  tin- 
plated  nails  or  tacks  in  their  mouths.  It  is  a  satisfaction  to  learn  from  Dr. 
AHce  Hamilton^^  that  while  the  manufacture  of  cheap  kitchen  ware  is  a  bad 
lead  trade  in  England,  the  ware  in  the  United  States  is  tinned  without  lead. 


6o6        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

The  washing  and  dipping  is  extremely  wet  and  disagreeable  work,  and 
the  subsequent  polishing  involves  inhalation  of  more  or  less  dust  of  a  mixed 
character.  The  acid  dips,  unless  the  hands  are  protected  with  rubber 
gloves  or  the  articles  are  handled  with  wooden  tongs,  are  liable  to  produce 
obstinate  eczema,  suppurative  pustules  and  even  symptoms  of  blood  poi- 
soning. Neisser^^  reports  a  number  of  such  instances  requiring  from  6-8 
weeks'  treatment. 

Tinners,  Tinkers,  Etc. — The  work  of  roofers,  tinners  and  tinkers  involves 
the  use  of  solder.  Apart  from  the  danger  of  lead  poisoning,  there  is  ex- 
posure either  to  carbon  monoxide  gas  from  open  charcoal  fire  or  the  products 
of  combustion  from  the  gasoline  torch,  also  to  the  irritating  fumes  of  hydro- 
chloric acid  and  possibly  arseniuretted  hydrogen,  if  the  acid  happens  to  be 
derived  from  arsenical  pyrites.  The  latter  risk  although  slight  may  also  be 
encountered  in  zinc,  tin  and  lead-plating  works. 

The  handling  of  tin  plates,  with  their  sharp  cutting  edges,  is  very  apt 
to  cause  injuries  of  the  hands  unless  they  are  properly  protected.  Roofers 
are  often  exposed  to  the  elements  and  as  a  result  many  contract  colds, 
catarrhal  and  rheumatic  affections,  and  inflammation  of  the  middle  ear. 
Burns  from  the  soldering  iron,  etc.,  are  not  infriequent.  Acute  and  chronic 
conjunctivitis  from  dust,  foreign  bodies,  and  exposure  to  acid  fumes  is 
also  common.  The  morbidity  hazard  of  the  Leipsic  tin- ware  factory  workers 
is  827  days  of  sickness  per  100  members  per  annum  and  the  mortality  hazard 
0.79  per  cent. 

Since  many  articles  of  tin  ware  are  also  painted  and  lacquered,  the 
element  of  danger  from  toxic  color  pigments  and  varnishes  must  likewise 
be  considered.  In  recent  years  the  process  of  mixing  copal  varnish  is  done 
by  means  of  compressed  air,  with  efficient  exhaust  ventilation,  so  that  the 
workers  are  no  longer  exposed  to  the  inhalation  of  this  dust.^* 

Tin  foil,  which  is  so  frequently  used  for  bottle  tops  and  wrappers  for 
cheese,  tobacco,  snuff,  cigarettes,  etc.,  should  be  spoken  of  as  lead  foil  as  it 
contains  generally  from  85  to  95  per  cent,  of  lead.  The  manufacture  of 
lead  foil  should  be  discouraged  as  it  exposes  the  workers  to  lead  poisoning 
and  is  not  wholly  free  from  danger  to  the  consumer. 

Vanadium. — This  rare  metal,  a  silvery  crystalline  substance,  is  obtained 
from  vanadinite  and  other  minerals.  The  pentoxide  is  used  in  photog- 
raphy as  a  developing  agent;  the  chloride  and  trioxide  are  used  as  a  mordant 
in  the  textile  printing  industry.  The  trioxide  is  also  used  in  the  manu- 
facture of  malleable,  ductile  steel,  such  as  is  used  for  making  the  chassis  of 
automobiles.  According  to  Dr.  Button, ^^  persons  employed  in  reduction 
plants  or  where  the  various  kinds  of  vanadium,  especially  the  trioxide,  are 
produced  are  liable  to  suffer  from  chronic  poisoning.  Among  the  early 
symptoms  he  mentions  a  peculiar  cachexia  not  unlike  chlorosis.  Irritation 
of  the  nose,  eyes  and  throat  and  a  dry  paroxysmal  cough  sufficiently  intense 
to  cause  pulmonary  hemorrhage  are  frequent  symptoms.     There  is  also  pro- 


IRON,    STEEL   AND    ALLIED    INDUSTRIES  607 

gressive  emaciation,  loss  of  appetite,  nausea,  diarrhea,  followed  by  obstinate 
constipation.  Albumin  casts  and  blood  corpuscles  are  often  present  in 
the  urine.  The  metal  is  eliminated  by  the  kidneys  and  has  also  been  de- 
tected in  the  feces,  saliva  and  sputum.  Continued  exposure  to  the  poison 
may  produce  tremors  of  the  extremities,  neuroretinitis,  amaurosis,  hysteria 
and  melancholia.  In  fatal  cases  Dr.  Dutton^^  found  the  lungs  highly  con- 
gested with  marked  destruction  of  the  alveolar  epithelium;  the  kidneys  were 
congested  with  evidence  at  times  of  an  acute  hemorrhagic  nephritis;  there 
was  also  more  or  less  evidence  of  gastro-enteritis.  While  0.  T.  Cruck- 
shank  has  produced  similar  lesions  in  animal  experimentation  with  vanadium, 
Lees^^  failed  to  find  that  there  is  such  a  disease  as  vanadiumism.  Button, 
however,  is  a  man  of  large  experience  and  his  observations  should  carry 
great  weight.  He  holds  that  a  fatal  termination  frequently  ensues  as  a  re- 
sult of  continued  exposure  to  the  poison,  but  that  the  prognosis  is  good  in 
the  absence  of  grave  renal,  lung,  blood  and  nervous  involvement. 

Treatment. — In  the  way  of  treatment  he  suggests  washing  out  of  the 
stomach  and  intestinal  evacuation  by  saline  laxatives.  For  the  relief  of 
cough,  terpin  hydr.  ]/i  gr.,  heroin  3^  gr.,  creosote  3^^  TH.  every  2  hours  and 
counter-irritation  over  chest,  also  inhalation  of  steam  vapors.  Turkish, 
Russian  or  cabinet  baths  have  proved  useful  to  aid  in  the  elimination  of  the 
poison,  while  in  the  less  acute  cases  the  administration  of  iron,  calisaya, 
strychnine,  cod-liver  oil,  and  outdoor  exercise  are  of  service  for  the  relief  of 
the  anaemic,  nervous  and  debilitated  condition. 

Preventive  Measures. — Perfect  ventilation  and  exhaust  flues  for  the 
removal  of  dust  and  fumes,  and  the  use  of  respirators,  are  essential.  The 
nasal  and  oral  cavities  should  be  cleansed  before  meals  and  upon  cessation 
of  work  by  means  of  a  spray  with  Dobell  solution,  followed  by  a  mentholated 
oil  spray.  Change  of  work  upon  appearance  of  suspicious  symptoms  is 
indicated. 

Robinson  and  Wilson"  examined  2860  workers  in  Foundry  and  Machine  Shop  Products 
in  Cincinnati,  and  diagnosed  27  cases  of  tuberculosis  (0.94  per  cent.).  About  44  others 
were  below  normal  health  for  this  occupation.  The  hazards,  such  as  all  kinds  of  dust, 
cold,  dampness,  fatigue,  and  noise  vary  in  degree  and  depend  not  only  upon  the  particular 
process,  but  also  upon  the  safeguards  in  force  and  the  sanitary  and  hygienic  conditions 
maintained  by  the  employer.  This  survey  revealed  gratifying  progress  in  the  sanitary 
and  hygienic  conditions,  and  also  that  there  is  need  for  further  improvement. 

Among  565  persons  employed  in  the  Tin  and  Sheet  Metal  Industry,  12  cases  of  tuber- 
culosis were  found.  Many  of  the  men  in  the  galvanizing  department  were  found  below  par 
and  in  one  of  the  three  establishments  visited  no  exhaust  was  provided  to  carry  off  the 
fumes,  and  certain  parts  of  the  factory  were  cold  and  damp.  Spitting  on  the  floors  was 
found  in  two  of  the  places  visited.     Piecework  and  speeding  up  was  also  in  evidence. 

REFERENCES 

1  Report  on  Conditions  of  Employment  in  the  Iron  and  Steel  Industry  in  the  U.  S.     Senate 
Document  No.  no,  62d  Congress,  ist  Session,  Washington,  D.  C,  1913,  Vol.  IV,  p.  29. 
*  Hirschberg. — Berliner  Klin.  Wochenschft.,  No.  6,  1898. 


6o8        ETIOLOGY   AND   PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

3  Crzellitzer. — La  Presse  Medicale,  December  8,  ico6. 

*  Apfelbach,  Geo.  L.— State  of  Illinois  Dept.  of  Factory  Inspection  Bull.,  April,  1914,  p.  18. 

6  Report  on  Conditions  of  Employment  in  the  Iron  and  Steel  Industry  in  the  U.  S.     Senate 

Document  No.  no,  62d  Congress,  ist  Session,  Wash.,  D.  C,  1913,  Vol.  Ill,  pp.  289-332. 
^  Report  on  Conditions  of  Employment  in  the  Iron  and  Steel  Industry  in  the  United  States, 

62d  Congress,  ist  Session,  Senate  Document  No.  no,  Washington,  i9i3,Vol.  IV,  p.  n. 
'  Ropke,  Friedrich.— Trans,  isth  Internat.  Congress  on  Hygiene,  Vol.  Ill,  Part  II,  page 

729,  Washington,  D.  C,  1913- 
8  Employment  in  the  Iron  and  Steel  Industry  in  the  U.  S.,  Vol.  IV,  62d  Congress,  ist 

Session,  Senate  Document  No.  117,  Washington,  D.  C,  1913. 
8  Ropke.— Transactions  15th  Internat.  Congress  on  Hygiene,  Washington,  D.  C,  1913, 

Vol.  Ill,  Part  II,  page  730. 
"  Hayhurst,  E.  R. — Industrial   Health    Hazards    and    Occupational    Diseases    in    Ohio, 

February,   1915. 
'1  62d  Congress,  ist  Session,  Senate  Document  No.   no,  Vol.  IV,  Washington,  1913. 
12  Hayhurst,    E.    R. — Industrial    Health   Hazards   and    Occupational    Diseases  in  Ohio, 

February,  1915. 
"  Ahrens. — Archiv  fiir  H3^giene,  Bd.  XXI. 

"  Hesse.— Vierteljahrschft.  f.  gerichtliche  Medizin,  Bd.  XXXVI. 
15  Report  on  the  Work  of  State  Inspectors  of  Health,  Mass.,  1910,  page  82. 
"  Sommerfeld. — Handbuch  der  Gewerbekrankheiten,  Berlin,  1898. 
1^  Report  of  the  State  Board  of  Health  of  Massachusetts  upon  the  Sanitary  Condition  of 

Factories,  Workshops,  etc.,  1907,  page  86. 
1*  Second  Report  of  the  Factory  Investigating  Commission,  State  of  New  York,  1913, 

Vol.  I,  page  256. 
^*  Sommerfeld.^ — Handbuch  d.  Gewerbekrankheiten,  Berlin,  1898. 
^^  Gottstein  and  Kayser. — Breslauer  Artzliche  Zeitschft.,  1881,  No.  9. 
2'  Roth. — ^Gewerbehygiene,  Berlin,  1906,  page  71. 
2^  Beyer. — Die  Fabrikindustrie  d.  Reg.  Bez.,  Dusseldorf,  1876. 
2'  Hoffman. — Dusty  Trades.     Bureau  of  Labor  Report,  Washington,  D.  C,  1908. 
^*  Mass.  State  Board  of  Health  upon  Sanitary  Condition  of  Factories,  etc.,  1907,  page  79. 
"^  Trans.  Internat.  Congress  on  Hygiene  at  Washington,  1913,  Vol.  Ill,  Part  II,  page  721. 
2^  Oliver's  Dangerous  Trades,  1902,  page  138. 

2'  Ropke,  F. — Trans.  15th  Internat.  Congress  on  Hygiene,  Vol.  II,  Part  III,  page  722,  Wash- 
ington, 1913. 
^*  Tatham. — Oliver's  Dangerous  Trades,  1902. 

2' Senate  Document  No.   no,  62d  Congress,  ist  Session,  Vol.  IV,  page  232,  Washing- 
ton, D.  C,  1913. 
^"  Report  of  the  State  Board  of  Health  of  Mass.  upon  the  Sanitary  Condition  of  Factories, 

etc.,  1907,  page  91. 
"  Salant,  W.,  Rieger,  J.  B.,  and  Treuthardt,  E.  L.  P.— Absorption  and  Fate  of  Tin  in  the 

Body.     Jour.  Biol.  Chem.,  1914,  XVII,  265;  Editorial  J.  A.  M.  A.,  Apr.  25,  19x4, 

page  1333. 
''  Oliver's  Dangerous  Trades,  1902,  page  319. 
"  Hamilton. — Lead  Poisoning  in  the  U.  S.     Trans.  15th  Internat.  Congress  on  Hygiene, 

etc.,  Vol.  Ill,  Part  II,  page  809,  Washington,  1913. 
"  Neisser. — Internationale  Ubersicht  liber  Gewerbehygiene,  Berlin,  1907,  pages  102,  217. 
"  Dutton,  W.  F.— J.  A.  M.  A.,  Vol.  LVI,  June  3,  1911,  page  1648. 
'^Lees. — Eng.  Min.  Jour.,  92-99. 
"  Robinson,  D.  E.,  and  Wilson,  J.  G.— U.  S.  Public  Health  Bulletin,  No.  73,  March,  1916. 


CHAPTER  V 
THE  PRINTING  AND  PUBLISHING  INDUSTRY 

BY  GEORGE  M.  KOBER.  M.  D.,  Washington,  D.  C. 

T>-pe  ;Metal.  T\'pe  Founding.  T>-pesetting.  Monotv-ping  and  Linotyping.  Stereo- 
t>T3ing.  Electrot>-ping.  Lead  Melting.  Binding-room  processes.  Chromo-Lithog- 
raphy.     Engraving.     Metal  Etching.     Photography.     Preventive  Measures. 

Printers. — During  the  year  1909,  the  printing  and  publishing  industry  in 
this  country  afforded  employment  to  388,446  wage  earners.  Of  these,  77.7 
per  cent,  were  males  and  22.3  per  cent,  females.  The  average  number  of 
wage  earners  under  16  years  of  age  was  6333,  of  which  about  one-sixteenth 
were  girls.  These  figures  cover  the  industry  as  a  whole,  which  includes 
music-printing,  book  binding  and  blank-book  making,  engraving  on  steel 
and  copper  plates  and  printing  from  such  plates,  and  lithographing. 

The  morbidity  and  mortality  of  printers  is  everywhere  very  high.  The 
statistics  of  German  printers  based  on  a  membership  of  54,000  from  1891- 
1904  gave  a  sickness  rate  of  461  per  1000  as  compared  with  375  in  the  occu- 
pied male  population.^  According  to  Schuler,  of  1000  Swiss  tj'pesetters  and 
founders  304.7  are  anually  taken  sick,  and  of  printers  250.  Diseases  of  the 
digestive  organs  predominate  (78  per  1000).  Diseases  of  the  respiratory 
system  come  next  (75  per  1000). 

The  death  rate  per  1000  employees  engaged  as  compositors,  printers  and 
pressmen  in  the  United  States  was  12.1.  Among  27  occupations  tabulated 
by  the  Census  Bureau  these  workers  occupy  the  third  rank  in  the  number  of 
deaths  from  tuberculosis,  and  in  38  occupations  tabulated  by  Professor 
Sommerfeld  the  German  printers  occupy  the  fifth  rank.  Albrecht^  reports 
that  the  statistics  of  the  Berlin  Sick  Benefit  Insurance  Companies,  covering 
a  period  of  33  years,  show  that  48.13  per  cent,  of  all  the  deaths  among  print- 
ers prior  to  1887  were  caused  by  consumption.  The  statistics  collected 
since  that  time  by  Sommerfeld  and  Silberstein'^  are  more  favorable,  since  only 
about  one-third  of  the  deaths  among  the  Berlin  printers  in  1903-1905  were 
caused  by  consumption.  This  gratifying  reduction  is  doubtless  the  result 
of  improved  sanitation  in  the  workrooms  as  required  by  regulations  of  the 
Federal  Council  of  the  German  Empire  which  went  into  effect  July  31,  1897. 
At  all  events,  in  a  total  membership  of  44,236  among  the  printers  of  Germany 
in  1905  only  134  or  3.03  per  1000  died  from  pulmonary  diseases  (tuberculosis 
not  being  separated  in  the  tabular  presentation).  The  corresponding  death 
rate  among  compositors  in  New  York  City  was  7. 1 7 ;  in  the  State  of  New  York 
4.04;  total  New  York  State  6.34;  Chicago  5.04;  Philadelphia  4.70,  total 
39  609 


6lO        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCtJPATIONAL   DISEASES 

United  States  5.02  and  London,  England  5.50.  See  interesting  study  of 
the  health  of  printers  by  George  A  Stevens.* 

The  undue  prevalence  of  consumption  among  printers  may  be  due  in 
part  to  the  fact  that  many  weakhngs  engage  in  this  occupation,  but  the  work 
itself  is  doubtless  an  important  predisposing  factor,  as  it  is  is  often  carried 
on  under  most  unfavorable  environments  and  in  an  atmosphere  rendered 
impure  by  the  products  of  respiration,  combustion  and  presence  of  type 
metal,  plumbago  dust  and  benzine  vapors  evolved  for  cleaning  purposes. 

Type  metal  is  an  alloy  containing  about  75  per  cent,  lead,  23  per  cent,  of 
antimony  and  about  2  per  cent,  of  tin,  copper  or  zinc.  During  the  wear  of 
the  type  more  or  less  dust  is  given  off  which  generally  collects  at  the  bottom 
of  the  type  cases.  One  gram  of  this  dust  upon  analyses  revealed  the  presence 
of  57.5  mg.  of  lead,  186.8  mg.  of  antimony  and  traces  of  arsenic.^ 

According  to  Fromm''  the  dust  collected  from  type  cases  contained  38.77 
per  cent,  of  lead,  the  dust  deposited  in  compositors  rooms  contained  1.95 
per  cent,  of  lead  and  the  floating  dust  in  such  establishments  revealed  the 
presence  of  0.54  to  1.55  per  cent,  of  lead.  Other  investigators  Hke  Panwitz^ 
detected  only  traces  of  lead  in  the  atmospheric  dust  of  compositors'  rooms. 

In  addition  to  this,  more  or  less  plumbago  is  used  in  electrotyping  which 
is  not  always  sufficiently  removed  before  the  type  is  redistributed.  It  will 
be  readily  understood  that  the  inhalation  or  ingestion  of  this  metalliferous 
dust  not  only  predisposes  to  diseases  of  the  respiratory  organs  but  also  causes 
lead  poisoning  in  various  degrees,  resulting  at  least  in  such  a  general  deteriora- 
tion of  the  health  of  the  workers  as  to  render  the  system  susceptible  to  the 
invasion  and  effects  of  tubercle  bacilli.  At  all  events.  Professor  Hahn^  points 
out  that  the  workers  both  in  Berlin  and  Vienna  between  1901  and  1907,  who 
are  most  exposed  to  plumbism,  viz.,  the  printers  and  type  founders,  also 
show  the  highest  mortality  from  tuberculosis.  Cases  of  pronounced  lead 
poisoning  are  not  very  common.  According  to  Sir  Thomas  Oliver^  only 
200  cases  were  reported  in  printers  in  Great  Britain  between  1900  and  1909. 
Conditions  are,  however,  worse  in  Germany  as  in  Leipzig  in  i  year  alone 
132  typists,  25  type  founders  and  9  music  typists  suffered  from  lead  poison- 
ing. In  Vienna,  between  1891  and  1900,  1308  cases  were  reported  with 
41,838  days  of  sickness  and  8  deaths,  exclusive  of  about  400  cases  of  a  milder 
type  which  did  not  incapacitate  the  individuals  for  work.  Females  and 
youthful  employees  are  especially  susceptible  to  lead  poisoning.  The  proc- 
esses in  which  the  workers  are  especially  exposed  to  injurious  factors  are  the 
following: 

Type  Founding. — It  was  held  for  a  long  time  that  the  old  process  of  casting 
type  involved  exposure  to  lead  and  arsenical  fumes,  as  the  antimony  fre- 
quently contains  arsenic.  This,  however,  according  to  Sternberg,^"  is  not 
the  case  as  the  melting  point  of  lead  is  326°C.  and  the  vapor  point  is  over 
iooo°C.;  the  latter  point  is  never  reached  in  this  process. 

Schuler,  cited  by  Silberstein,^^  has  pointed  out  that  the  so-called  lead 


THE   PRINTING    AND   PUBLISHING   INDUSTRY  6ll 

fumes  complained  of  by  type  founders  are  acrolein  vapors,  due  to  the  presence 
of  wax,  fat  or  oils  used  in  fluxing  the  metals  (see  Acrolein).  The  polishing 
of  the  type  by  means  of  files  and  machines  is  usually  done  by  female  labor 
and  youthful  employees  and  involves  exposure  to  lead  dust,  and  the  sorting 
and  packing,  also  largely  done  by  female  labor,  involves  at  least  the  risk 
incident  to  the  constant  handling  of  a  lead-containing  metal. 

T3rpesetting. — The  compositor  is  chiefly  exposed  to  the  inhalation  and 
ingestion  of  the  dust  from  the  type  cases;  the  absorption  by  the  skin  is 
probably  insignificant  as  only  the  apex  of  the  thumb  and  index-finger  are 
brought  into  contact  with  the  metal  in  setting  up  or  distributing  of  the  type; 
the  skin  of  these  fingers  soon  becomes  hardened,  rendering  the  chances  of 
absorption  quite  remote.  On  the  other  hand,  it  should  be  remembered  that 
some  compositors,  especially  youthful  members,  are  in  the  habit  of  moistening 
their  fingers  in  order  to  get  a  better  hold  of  the  type,  and  of  holding  the  type 
between  their  teeth  while  correcting  proof.  This,  together  with  smoking 
and  an  equally  pernicious  habit  of  eating  fruit  and  lunches  with  unwashed 
hands,  is  a  frequent  mode  for  the  ingestion  of  lead.  Prof.  Van  Eyk,  cited 
by  De  Vooys  and  quoted  by  Oliver, ^^  requested  a  number  of  printers,  after 
several  hours'  work  with  type,  to  wash  their  hands  in  a  weak  solution  of 
hydrochloric  acid  and  found  on  a  average  from  6  to  1 5  mg.  of  lead  in  each 
wash  basin. 

The  danger  from  type  case  dust  could  be  materially  reduced  by  proper 
construction  of  the  cases.  Strasser,  nearly  30  years  ago,  suggested  a  type 
case  with  a  perforated  tin  bottom,  placed  within  another  case;  the  dust 
would  naturally  drop  from  the  upper  to  the  lower  case,  and  if  the  latter  was 
provided  with  a  concave  and  rounded  bottom  its  collection  and  removal 
would  be  materially  facilitated,  especially  since  the  introduction  of  vacuum 
cleaners.  In  spite  of  this  practical  suggestion,  the  writer  has  never  seen 
such  cases  in  use,  and  even  in  the  Government  Printing  Office  in  Washington, 
an  otherwise  high-grade  institution,  the  old  style  of  cases  are  still  in  use,  but 
are  now  cleaned  by  the  vacuum  system  instead  of  by  bellows  as  formerly. 

Monotyping  and  Linotyping. — Both  of  these  processes,  the  former  casting 
single  letters  and  the  latter  an  entire  line,  have  superseded  in  all  large  print- 
ing estabhshments  the  old  methods  of  type  founding  and  typesetting.  The 
work  is  nearly  all  done  automatically  by  machines  and  hence  the  danger 
from  dust,  or  handling  of  the  type,  has  been  greatly  reduced.  For  reasons 
already  given  there  is  no  danger  from  lead  or  arsenical  fumes  from  the  melt- 
ing pots.  The  operatives,  however,  are  exposed  to  irritating  acrolein  vapors 
from  materials  used  in  fluxing  the  metal,  such  as  wax.  In  monotype  ma- 
chines which  operate  directly  over  the  metal  pots,  oil  from  the  machine  is 
liable  to  drip  into  the  molten  metal  and  aggravates  the  offensive  acrolein 
vapors.  All  of  this  should  be  obviated  by  suitable  hoods  and  exhaust  flues 
connected  with  each  pot;  this  method,  however,  must  be  regulated  so  as  not 
to  produce  an  excessive  draught  and  thereby  overheat  the  metal. 


6l2        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

Stereotyping.— In  the  process  of  stereotyping  the  type  forms  are  placed 
in  steam  or  gas,  or  preferably  electric  heated  presses,  for  the  purpose  of  mak- 
ing a  negative  impression  upon  paper  specially  prepared  for  the  purpose. 
The  impression  or  matrix  is  placed  in  suitable  moulds,  into  which  the  molten 
metal  is  either  poured  by  a  ladle  or  pumped  automatically,  until  the  desired 
thickness  of  the  slab  has  been  attained.  This  process,  as  well  as  the  pre- 
liminary act  of  melting,  necessarily  involves  handling  of  the  lead  and  exposure 
to  its  toxic  effects. 

The  formed  plates  are  subsequently  trimmed.  Dr.  Manning  of  the 
Government  Printing  Office  beheves  that  the  finishers  of  the  plates,  who 
handle  only  the  smooth,  hard,  bright  slabs  run  the  least  risk  of  lead  poisoning. 

Electrotyping. — In  this  process  an  impression  of  the  set-up  type  is  made 
upon  a  layer  of  wax,  both  the  form  and  the  wax  having  previously  been  cov- 
ered with  plumbago  to  prevent  adhesion  of  the  surfaces.  The  wax  matrix 
is  then  placed  in  a  closed  box  and  more  plumbago  is  blown  on  it  by  means  of 
compressed  air,  which  is  an  extremely  dusty  process.  Recently  modern 
establishments  have  adopted  a  wet  method  which  consists  in  the  application 
of  a  liquid  graphite-paste  by  means  of  a  hand  brush,  or  by  having  the  matrix 
move  automatically  upon  an  incline,  back  and  forth  through  the  graphite 
mixture.  Dr.  Manning  informs  me,  that  by  this  method  the  dust  production 
has  been  reduced  fully  90  per  cent,  in  the  Government  Printing  shop.  Iron 
filings,  followed  by  a  solution  of  sulphate  of  copper,  are  next  applied  to  the 
wax  impression  to  form  a  plate,  which  is  then  immersed  in  the  electrotyping 
solution  to  secure  the  desired  thickness  of.  copper  deposit.  When  this  is 
attained  the  copper  plate  is  removed  from  the  wax  and  thoroughly  cleaned. 
It  is  then  placed  face  downward  in  a  tray  and  backed  by  pouring  electro- 
type metal  lead  on  it;  all  of  which  necessarily  involves  considerable  handling 
of  lead  and  exposure  to  irritating  fumes. 

Lead  Melting. — The  men  engaged  in  melting  the  new  metal  and  old  slugs 
are  exposed  to  the  risk  of  plumbism  from  handling  the  metal  and  breathing 
its  toxic  fumes  if  the  temperature  should  reach  the  vaporizing  point.  The 
temperature  of  the  rooms  in  which  this  process  and  type  founding  is  carried 
on  is  also  frequently  above  86°. 

In  the  Government  Printing  Office  the  melting  is  done  in  special  rooms 
after  the  usual  working  hours  and  the  men  are  shifted  to  other  work  at  the 
expiration  of  i  week.  The  melting  pots  are  placed  between  open  windows 
so  as  to  insure  copious  ventilation,  aided  by  revolving  fans.  It  is  said  that 
the  hoods  interfere  with  the  stirring  of  the  metal. 

Summary. — The  chief  occupational  diseases  in  the  printing  industry  are 
tuberculosis,  other  diseases  of  the  respiratory  system,  and  plumbism. 
Diseases  of  the  digestive  organs  are  also  quite  common,  and  compositors  and 
proofreaders  not  infrequently  develop  neurasthenia.  Compositors,  and  all 
others  obliged  to  maintain  a  standing  position,  are  hable  to  develop  flat- 
foot,  varicose  veins  and  ulcers.     There  is  also  evidence  to  indicate  that  the 


THE    PRINTING   AND    PUBLISHING   INDUSTRY  613 

married  women  employed  in  this  industry,  probably  as  a  result  of  lead  in- 
toxication, miscarry  more  frequently  than  women  engaged  in  other  occupa- 
tions. According  to  Silberstein'^  the  percentage  in  Berlin  in  1905  was  2.4 
and  1.7  respectively.  According  to  the  same  author  inflammatory  diseases 
of  the  skin  are  also  more  common  in  the  printing  industry,  viz.,  20  per  1000 
against  an  average  of  13  in  other  occupations.  Eczema  of  the  hands 
and  forearms  in  the  workmen  who  handle  the  type  forms  is  evidently 
caused  by  the  irritation  of  certain  agents  such  as  turpentine,  petroleum, 
benzine,  lye,  etc.,  employed  for  the  removal  of  printer's  ink.  Quite  re- 
cently Zellner  and  Wolffs*  have  called  attention  to  the  undue  prevalence  of 
these  skin  aflfections,  and  attribute  them  to  trade  substitutes  for  the  oil  of 
turpentine,  which  was  formerly  almost  exclusively  employed.  Among  the 
substitutes  were  found  inferior  benzine,  lye,  poorly  refined  petroleum,  and 
impure  turpentine,  called  "pine  oil."  Of  37  samples  of  "pine  oil"  and  other 
cleaning  materials  examined  32,  or  87  per  cent.,  contained  impure  benzine  or 
lye,  and  the  turpentine  used  was  also  found  to  be  adulterated  with  impure 
benzine.  It  is  well  known  that  even  pure  oil  of  turpentine  and  refined 
petroleum  may  prove  irritants  to  sensitive  skins,  but  they  are  at  present  the 
least  objectional  agents  employed  and  every  effort  should  be  made  to  suppress 
the  use  of  lye  and  irritant  adulterants  or  substitutes.  The  Government  Print- 
ing Office  provides  lye  and  the  men  are  enjoined  to  immerse  their  hands  sub- 
sequently in  a  solution  of  vinegar,  while  those  working  in  acid  dips  are 
expected  to  neutralize  the  acid  by  immersion  into  a  weak  ammonia 
solution,  but  this  method  has  not  wholly  prevented  the  occurrence  of 
eczema. 

Binding  Room  Processes. — The  work  is  generally  carried  on  in  unfavor- 
able surroundings,  as  regards  light  and  air.  Dust,  heat  and  exposure  to 
wood  alcohol,  from  the  shellac  employed,  constitute  the  chief  injurious 
factors.  Persons  employed  in  folding  heavy  paper  with  their  hands  are 
liable  to  develop  cysts  of  the  wrist  tendons  in  consequence  of  constant  local 
pressure. 

Preventive  Measures. — In  view  of  the  foregoing  it  is  evident  that  the 
utmost  precaution  should  be  taken  to  reduce  the  dangers  in  printing  estab- 
lishments to  a  minimum.  All  processes  involving  the  handling  of  molten 
metal  should  be  carried  on  in  the  upper  stories  or  in  separate  buildings,  to 
facilitate  the  removal  of  injurious  fumes  by  means  of  hoods  and  exhaust 
ventilation. 

Cleaning  of  electrotype  plates  for  the  removal  of  caked  plumbago  should 
be  done  by  means  of  steam  in  a  "boiling  chamber"  and  the  plates  lifted  in 
and  out  by  hooks.  This  method,  in  vogue  in  the  Government  Printing  Office, 
has  reduced  dust  production  to  a  minimum  and  also  secured  a  thorough  re- 
moval of  the  graphite.  Perfect  cleanliness  of  the  establishment  aided  by 
vacuum  cleaners  should  be  observed. 

Light,  air  space,  general  ventilation,  temperature,  humidity,  spittoons 


6 14        ETIOLOGY   AND   PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

and  facilities  for  personal  cleanliness  should  be  in  harmony  with  modern 
ideas  of  factory  sanitation. 

Chromo -lithography. —This  growing  industry  affords  employment  to  a 
large  number  of  persons,  including  females  and  minors.  The  work  is  often 
carried  on  under  unfavorable  hygienic  conditions  as  regards  light,  air  space, 
and  ventilation,  which  is  all  the  more  regrettable  as  some  of  the  processes 
involve  the  employment  of  injurious  agents,  such  as  arsenic  pigments,  chro- 
mium, lead  and  bronze  powder.  In  the  room  where  the  prints  are  made 
the  air  is  usually  charged  with  vapors  of  turpentine  and  benzine. 

The  lithographic  process  varies  in  different  establishments;  the  design  or 
picture  may  be  engraved  by  means  of  a  diamond  or  steel  needle  upon  a  fine 
grained  sandstone,  generally  imported  from  Bavaria,  or  the  drawing  may  be 
made  upon  the  stone  with  a  greasy  composition.  In  photo-lithography  the 
printing  surface  is  largely  prepared  by  a  photographic  process.  In  all  of 
the  processes  of  chromo-lithography  the  stone  is  dampened  on  those  portions 
of  the  design  which  are  not  to  appear  in  the  first  printing;  this  prevents 
taking  the  ink  or  colors.  The  actual  application  of  colors,  and  press  work, 
is  performed  by  another  set  of  operatives.  According  to  Leiser^^  in  a  total 
membership  of  11,807  employees  in  this  industry,  in  Berlin  during  1904, 
2002  males  and  1840  females,  or  32.6  per  cent.,  were  reported  sick,  with 
90  deaths;  of  the  sick  about  12  per  cent,  suffered  from  tuberculosis;  11  per 
cent,  had  skin  affections,  especially  obstinate  forms  of  eczema  caused  by 
contact  with  acid  dips,  bronzing  powder,  toxic  color  pigments,  impure  tur- 
pentine, etc.;  10.5  per  cent,  of  the  sick  suffered  from  disorders  of  the  digestive 
system  and  19  per  cent,  of  the  females  were  anaemic.  There  were  356 
accidents,  mostly  contusions  of  the  fingers  contracted  in  press  work.  Cohen 
estimates  that  about  45  per  cent,  of  the  lithographers  suffered  from  near 
sight  or  other  visual  defects. 

The  operation  of  bronzing  may  be  done  by  the  dry  or  wet  method  by 
hand  or  machinery.  The  wet  process  by  inks  has  not  proved  satisfactory 
from  the  artistic  standpoint  and  machines  are  rapidly  displacing  the  dry 
bronzing  by  hand.  The  machines  print  the  designs  in  sizing  and  the 
sheets  are  fed  into  the  bronzing  machines  from  which,  however,  accord- 
ing to  the  Massachusetts  Report  of  the  State  Board  of  Health, ^«  "in  spite 
of  their  metallic  coverings  and  exhaust  ventilation  the  bronze  powder  escapes 
freely  into  the  air.  The  boys  who  run  the  five  machines  wear  handkerchiefs 
over  the  nose  and  mouth.  They  look  pale  and  unhealthy  and  all  show  the 
characteristic  green  perspiration  due  to  contact  with  bronze.  The  great 
majority  of  the  employees  appear  to  be  healthy."  (See  also  bronzing  powder, 
page  497.) 

The  danger  from  lead  poisoning  is  quite  pronounced  in  the  manufacture 
of  so-called  lithographic  transfers  intended  for  decorative  purposes  on  porce- 
lain ware,  ornamental  glass  for  windows,  art  and  enameled  goods,  etc.  In 
this  process  metallochrome  powder,  often  containing  50  to  60  per  cent,  of 


THE    PRINTING   AND   PUBLISHING   INDUSTRY  615 

white  lead,  is  used.  The  work  of  rubbing  the  powder  over  the  sheets  of 
paper  is  usually  done  by  females,  many  of  whom  show  evidence  of  chronic 
lead  poisoning;  indeed  it  was  not  until  several  deaths  from  acute  lead  poison- 
ing were  reported  in  this  industry  that  the  real  cause  was  discovered.  Be- 
tween 1895  and  1905,  46  cases  were  reported  in  Great  Britain,  and  in  the 
latter  year  21  cases  with  355  days  of  sickness  occurred  in  one  of  the  German 
establishments.  Several  cases  were  reported  by  the  IHinois  Occupational 
Diseases  Commission  in  1910.  Since  that  time  the  dangers  have  been  mate- 
rially diminished  as  the  "laying  on"  of  the  powder  is  now  done  on  tables 
covered  with  a  glass  case,  the  hands  protected  with  rubber  gloves  perform 
the  work  through  suitable  openings,  and  the  dust  evolved  in  the  glass  case 
is  rapidly  removed  by  exhaust  ventilation.^'^ 

Neisser^^  points  out  another  source  of  danger  in  this  industry  by  reporting 
a  case  of  double  cataract  in  a  man  who  melted  over  an  open  flame  a  color 
mixture  composed  of  wax,  stearin,  Venetian  soap,  asphalt,  pitch,  turpentine 
and  oil  of  lavender,  mixed  in  the  order  named.  The  affection  was  attributed 
to  the  inflammable  character  of  the  vapors  evolved  during  the  melting 
process  and  the  manufacturer  has  guarded  against  a  recurrence  of  the  evil 
by  providing  suitable  exhaust  ventilation  and  eye  protectors. 

Engraving. — ^The  work  of  engraving  upon  steel,  copper  or  other  material 
involves  not  only  considerable  eye  strain,  but  also,  in  the  absence  of  suitable 
work  benches,  a  faulty  position  which  interferes  with  the  respiratory  move- 
ments. Steel  and  copper  plate  engravers  are  also  exposed  to  mercury,  and 
makers  of  stamping  devices  and  seals  to  lead  and  the  fumes  of  nitric  acid. 
The  latter  agent  is  likewise  employed  in  mints  in  connection  with  the  coinage 
of  money.  According  to  Sommerfeld,  cited  by  Zadek,^^  73.6  per  cent,  of  all 
the  deaths  among  this  class  of  workers  in  Berlin  were  caused  by  diseases  of 
the  respiratory  system,  inclusive  of  62.1  per  cent,  from  tuberculosis;  this  is 
in  part  accounted  for  by  the  fact  that  so  many  weakHngs  engage  in  this  pur- 
suit. Visual  defects,  neurasthenia,  diseases  of  the  digestive  system,  are 
also  quite  common.  Plate  printers  who  have  to  look  constantly  at  bright 
plates,  suffer  not  only  from  eye  strain  but  occasionally  also  from  conjunc- 
tivitis and  even  retinitis. 

Photo  Engravers. — Photo-engravers  handle  benzol  for  dissolving  rubber 
films,  alcohol  and  ether,  in  coUodium  films,  strong  acetic  acid  for  the  removal 
of  films;  they  are  also  exposed  to  gas  fumes  and  ammonium  dichromate  in 
sensitizing  copper  plates,  and  to  ferric  chloride  and  nitric  acid  fumes  in  etch- 
ing. The  Report  of  the  Photo-engraver's  Union  for  19 14,  cited  by  Hayhurst,-" 
discloses  the  fact  that  out  of  217  deaths  since  1903,  88,  or  nearly  41  per  cent., 
were  due  to  tuberculosis.  During  the  year  1914,  five  cases  of  bichromate  and 
one  case  of  cyanide  poisoning  were  reported. 

Metal  Etching. — In  the  etching  process  of  zinc  or  copper  plates  nitric 
acid  in  the  proportion  of  one  part  to  four  of  water  is  used,  evolving  large 
volumes  of  nitrous  fumes,  which  are  distinctly  injurious,  unless  the  process  is 


6l6        ETIOLOGY   AND   PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

carried  on  under  hoods  equipped  with  efficient  exhaust  ventilation.  There 
is  also  exposure  to  mercury  in  some  of  the  processes,  and  etching  on  brass 
involves  the  use  of  chloride  of  mercury. 

Neisser^i  reports  that  in  one  of  the  establishments  at  Nancy  chromic 
and  phosphoric  acid  was  employed  as  a  secret  process  in  the  etching  of  zinc 
plates,  causing  characteristic  chrome  ulcers  on  the  hands,  arms,  neck  and 
face  in  seven  of  the  45  persons  engaged  in  the  work. 

Photography. — Workers  in  photographic  establishments,  especially  those 
engaged  in  the  developing  process  are  exposed  to  bad  air  and  light  and  also 
to  a  number  of  industrial  poisons,  such  as  the  bromine,  chromium,  metol, 
cyanogen,  platinum,  vanadium,  aniline,  and  mercurial  compounds.  They 
also  handle  more  or  less  iodine,  nitrate  of  silver  and  copper  sulphate. 

In  an  examination  of  40  studios  in  Chicago  by  Dr.  Karasek-^  platinum 
paper  was  found  to  be  the  cause  of  eight  cases  of  poisoning,  characterized 
by  "pronounced  irritation  of  the  throat  and  nasal  passages,  causing  violent 
sneezing  and  coughing;  bronchial  irritation,  causing  such  respiratory  diffi- 
culties as  to  preclude  the  use  of  the  paper  entirely  for  some  individuals, 
and  irritation  upon  contact  with  the  skin,  causing  cracking,  bleeding  and 
pain." 

Metol  poisoning  characterized  by  an  erythematous  rash  of  the  hands 
and  arms,  occasionally  involving  other  parts  of  the  body  and  giving  rise  to 
ulcers,  were  found  in  31  cases  in  this  same  study. 

The  developing  process  very  frequently  gives  rise  to  inflammatory  con- 
ditions of  the  hands  (eczema)  ulcers  and  pigmentation  unless  protected  by 
rubber  gloves. 

Chrome  compounds  and  aniline  colors  are  also  used  in  the  composition 
of  hectograph  inks,  and  hence  are  a  possible  source  of  danger  to  the  makers 
and  users  of  the  ribbons. 

Robinson  and  Wilson^^  report  that  in  an  examination  of  1376  employees 
inclusive  of  449  females  in  the  Printing  and  Publishing  Industry  in  Cincinnati, 
only  five  were  found  with  evidences  of  tuberculosis,  a  percentage  of  0.36;  17 
others  were  noted  as  below  the  normal  standard  of  health.  This  remarkable 
low  rate  of  incidence  is  attributed  to  the  fact  that  the  two  establishments  where 
the  greater  number  of  examinations  were  made,  were  excellent  examples  of 
how  printing,  publishing,  and  binding  industries  should  be  conducted.  None 
of  the  five  cases  could  be  charged  to  the  occupation  or  bad  working  conditions. 
One  of  the  establishments  was  located  in  the  outskirts  of  the  city  with  large 
grounds  and  excellent  sanitary  and  working  conditions.  The  other  large 
plant,  manufactured  Christmas  cards,  calendars,  cards,  etc.  and  employed 
chiefly  girls.  The  work  was  clean  and  apparently  without  hazard.  It  is  to 
be  hoped  that  these  examples  of  sanitation  in  hazardous  occupations  will  be 
emulated. 

One  case  of  tuberculosis  was  found  in  an  examination  of  118  electrotypers. 
The  chief  hazard  reported  was  the  excessive  heat  and  dryness  in  the  plating 


THE    PRINTING    AND    PUBLISHING    INDUSTRY  617 

room,  the  temperature  in  summer  in  spite  of  hoods  and  exhaust  fans  was 
100  degrees  and  the  relative  humidity  35.  In  winter  the  temperature  was 
76  degrees  with  a  relative  humidity  of  13. 

Among  366  workers  inclusive  of  99  females  engaged  in  lithographing  not 
a  single  case  of  tuberculosis  was  found,  and  only  eight  could  be  classified  as 
below  the  normal  standard  of  health.  This  favorable  showing  is  attributed 
by  the  investigators  to  the  absence  of  special  hazards,  commendable  sanitary 
and  hygienic  conditions,  good  wages,  a  full  hour  for  lunch,  absence  of  promis- 
cuous spitting,  and  absence  of  noise  and  the  high  nervous  strain  observed 
in  many  other  industries. 

REFERENCES 

1  Professor  Martin  Hahn. — Die   Gesundheitsverhaltnisse  im  polygraphischen   Gewerbe 

Deutschlands,  etc.,  Berlin,  1910. 

2  Albrecht. — Roth's  Compendium  der  Gewerbekrankh.,  Berlin,  1904,  page  56. 

3  Sommerfeld,  cited  by  Silberstein. — Weyl'sHandbuchder  Arbeiterkrankh.,  1908,  page  255. 
■*  Twenty-fourth  Annual  Report  of  the  Bureau  of  Labor  Statistics,  New  York. 

5  Roszahegyi. — Arch.  f.  Hygiene,  Munchen  and  Leipzig,  Vol.  Ill,  page  522. 

«  Fromm. — Uber  den  bleihaltigen  Staub  der  Setzereien.     Hgg.  Rundschau.,  1898. 

'  Arbeit,  aus  d.  Kaiserl.  Gesundheitsamtes,  Bd.  XIII. 

*  Hahn. — Op.  ciL,  pages  22,  58,  59. 

9  Oliver.— Bulletin  Bureau  of  Labor  No.  95,  July,  1911,  pages  65,  71. 
1°  Sternberg. — Med.  Reform,  1906,  Nos.  49,  50. 
1^  Weyl's  Handbuch  d.  Arbeiterkrankh.,  1908,  page  253. 
1- Oliver. — Bull.  Bureau  of  Labor,  No.  95,  July,  1911,  Washington,  D.  C. 
1^  Silberstein,  R. — Weyl's  Handbuch  der  Arbeiterkrankheiten,  Jena,  1908. 
^*  tJber  die  Ursachen   der   Hauterkrankungen  in  Buchdruckereien  Ztschft.  f.  Hyg.  and 
Infectionskrank.,  1913,  LXXV,  page  69.     See  also  page  1815.    J.  A.  M.  A.,  Novem- 
ber IS,  1913. 
i^Leiser. — Weyl's  Handbuch  der  Gewerbekrankheiten,  1908,  page  339. 
1^  Report  on  the  Sanitary  Condition  of  Factories,  Workshops,  etc.,  1907,  page  80. 
'^  Oliver's  Dangerous  Trades,  London,  1902. 

1^  Neisser.^ — Internal,  tjbersicht  iiber  Gewerbehygiene,  1907,  page  123. 
"  Zadek. — Weyl's  Handbuch  d.  Arbeiterkrankh.,  1908,  page  141. 
2°  Hayhurst,    E.    R. — Industrial    Health    Hazirds   and    Occupational    Diseases   in    Ohio, 

February,  1915. 
*'  Neisser.- — Internationale  tjbersicht  iiber  Gewerbehygiene,  Berlin,  1907,  page  94. 
*^  Report  of  the  Illinois  State  Commission  on  Occupational  Diseases,  January,  191 1. 
"  Robinson,  D.  E.,  and  Wilson  J.  G.— U.  S.  Public  Health  Bulletin  No.  73,  March,  1916. 


CHAPTER  VI 
MINING,  QUARRYING  AND  ALLIED  INDUSTRIES 

BY  GEORGE  M.  KOBER,  M.  D.,  Washington,  D.  C. 

Air  of  Mines.  Carbon  Monoxide.  Sulphureted  Hydrogen.  Marsh  Gas.  Fire-damp. 
After-damp.  Explosive  Conditions  in  Mines.  Diseases  of  Miners,  Tunnel  Work- 
ers and  Quarrymen.  Preventive  Measures.  Stonecutters  anad  Marble  Workers. 
The  Clay  Products  Industry.  The  Pottery,  Terra-cotta  and  Fire  Clay  Product 
Industry.  Sagger  Making.  Bisque  Making.  Glaze  Mixing.  Glaze  Dipping. 
Decorating  Department.  Lime  Burning.  Meerschaum.  Mica.  Cement  Work- 
ers. Asphalt  Workers.  Brick  and  Stone  Masons.  Plasterers.  Paperhangers. 
Emery  and  Corundum.  Emery  and  Sandpaper  Making.  Diamond  Cutters  and 
PoHshers  of  Precious  Stones.  The  Glass  Industry.  Glass  Blowing  and  Polishing. 
Mineral  Wool.  Workers  in  Rontgen  Tubes  and  Rontographers.  Radium.  Pre- 
ventive Measures. 

Miners  and  Quarrymen. — Mining,  even  under  the  best  conditions,  is  one 
of  the  most  laborious  and  dangerous  occupations,  and  according  to  the  German 
statistics  cited  by  Lindemann^  it  occupies  the  seventh  place  in  reference  to 
accident  occurrence.  The  liability  to  accidents  is  very  much  greater  than 
in  other  occupations,  but  has  been  reduced  by  efiS.cient  safeguards.  The 
accident  fatality  rate  among  German  miners  has  gradually  decreased  from 

3.18  per  1000  in  1879  to  2.25  per  1000  in  1910,  while  the  rate  among  American 
coal  miners  has  unfortunately  increased  from  2.32  per  1000  in  1886  to  3.30  in 
1914,  as  compared  with  0.96  for  India,  1.02  for  Belgium,  1.04  for  Austria,  1.69 
for  France,  1.36  for  Great  Britain,  2. 11  for  Germany,  and  2.92  for  Japan.  Pro- 
fessor Holmes  ascribes  the  greater  frequency  of  accidents  in  the  mines  of  this 
country  to  several  factors,  such  as  the  rapid  development  and  still  unorganized 
condition  of  the  industry,  to  unskilled  foreign  labor  of  a  migratory  disposi- 
tion unable  to  understand  the  language,  to  difference  in  details  in  the  rules 
and  regulations  adopted  by  different  mining  companies,  and  last  but  not  least 
to  the  sharp  competition,  especially  in  coal  mining,  as  a  result  of  which  the 
average  American  coal  miner  produces  three  times  as  much  coal  each  working 
day  as  is  produced  daily  by  each  miner  in  Great  Britain.  On  the  basis  of  the 
number  of  men  killed  for  each  million  of  tons  mined,  the  death  rate  for  the 
period  of  1901-1910,  as  given  by  Holmes,  was  5.83  for  the  United  States, 
4.40  for  Great  Britain,  5.05  for  Austria,  5.56  for  Belgium,  7.55  for  Germany, 

7.19  for  France,  9  for  India,  and  22.71  for  Japan.  During  1913  among 
747,644  wage  earners  2785  men  were  killed  in  the  coal  mines.  In  the  same 
year  among  193,088  workers  in  the  metal  mines  683  were  killed,  or  a  fatality 
rate  of  3.54  per  1000  as  compared  with  4.19  in  1911.     In  addition  to  the  fatal 

618 


MINING,   QUARRYING    AND    ALLIED   INDUSTRIES  619 

accidents  in  metal  mining  there  were  5890  serious  injuries,  such  as  fractures 
of  arms,  legs  or  ribs,  and  other  injuries,  causing  the  loss  of  more  than  20  days' 
work,  and  27,081  slight  injuries  involving  disability  from  i  to  20  days. 
The  economic  loss  from  all  three  classes  of  injuries  due  to  accidents  in  coal 
mines,  according  to  the  U.  S.  Bureau  of  Mines,^for  1911  would  total  $14,142,- 
000;  and  the  loss  of  38,853  lives  in  the  coal  mines  of  the  U.  S.  in  the  19  years 
from  1896  to  1914  would  amount  to  over  $194,000,000. 

The  causes  of  fatal  coal  mine  accidents  in  the  U.  S.  during  19 12  are  given 
by  F.  W.  Horton-  as  follows:  Falls  of  roof  (coal,  rock,  etc.),  41-19  percent.; 
falls  of  coal  other  than  roof  coal,  7.58  per  cent.;  mine  cars  and  locomotives, 
15.34  per  cent.;  gas  explosions  and  burning  gas,  6.95  per  cent.;  coal  dust 
explosions,  1.27  per  cent.;  explosions  of  coal  dust  and  gas,  4.53  per  cent.; 
explosives,  inclusive  of  suffocation  by  gases  from  explosives,  5.64  per  cent.; 
suffocation  from  mine  gases,  0.42  per  cent.;  electricity  (shock  or  burns),  3.22 
per  cent.;  animals,  0.30  per  cent.;  mining  machines,  0.59  per  cent.;  mine 
fires,  burned,  suffocated,  0.47  per  cent.;  other  causes,  2.20  per  cent.,  making  a 
total  of  89.79  per  cent,  killed  underground.  2.29  per  cent,  of  the  total  fatal 
accidents  occurred  in  shafts;  about  one-half  were  caused  by  falling  down 
shafts  or  slopes  and  from  objects  falling  down  shafts  or  slopes,  breaking  of 
cables  and  chains,  overwinding  and  other  causes.  7.92  per  cent,  of  the  fatal 
accidents  occurred  on  the  surface  and  were  caused  by  mine  cars  and  locomo- 
tives, electricity,  machinery,  boiler  explosions,  railway  cars  and  locomotives 
and  other  causes. 

In  275  coal  mine  accidents  in  the  U.  S.  up  to  and  including  191 2  in  which 
5  or  more  men  were  killed,  involving  a  total  loss  of  6777  men,  51 11  or  about 
75  per  cent,  were  killed  by  gas  and  coal  dust  explosions,  1082  or  over  15  per 
cent,  lost  their  lives  by  mine  fires,  159  were  killed  by  explosives,  123  by  inrush 
of  water,  105  by  falls  of  roof  and  coal,  26  by  mine  cars  and  locomotives,  89 
by  shaft  accidents  and  82  by  other  causes. 

According  to  Fay,^  about  two-thirds  of  the  total  deaths  and  injuries  that 
occurred  in  or  about  metal  mines  in  19 13  were  caused  as  follows:  Of  the  fatal 
aciddents  36.16  per  cent,  were  due  to  falls  of  ore  or  rocks  from  roof,  wall  or 
bank;  13.04  per  cent,  to  explosives;  12.31  per  cent,  to  falhng  down  slope,  shaft 
or  winze,  and  11.42  per  cent,  to  haulage  systems. 

Of  the  serious  accidents  24.12  per  cent,  are  due  by  falls  of  roof,  wall  or 
bank;  17.22  per  cent,  to  car  and  haulage  systems;  9.43  per  cent,  to  machinery, 
and  12.69  per  cent,  to  timber  and  hand  tools.  Of  the  shght  accidents,  22.65 
per  cent,  are  due  to  falls  of  roof,  wall  or  bank;  13.27  per  cent,  to  car  and  haul- 
age systems;  8.83  per  cent,  to  machinery,  and  15.78  per  cent,  to  timber  and 
hand  tools. 

Air  of  Mines. — The  air  of  mines  differs  in  composition  from  the  atmos- 
pheres in  this,  that  there  is  always  an  excess  of  carbon  dioxide,  also  known  by 
miners  as  black-darnp  or  choke-damp. 

It  is  a  product  of  decomposition  and  combustion  and  of  respiration  of 


620        ETIOLOGY    AND    PROPHYLAXIS    OF    OCCUPATIONAL    DISEASES 

men  and  animals,  and  is  naturally  increased  by  the  process  of  breathing,  by 
the  burning  of  miners'  lamps  and  by  blasting  operations,  and  its  presence  in 
dangerous  volumes  extinguishes  a  flame.  Carbon  dioxide  is  not  itself  a  toxic 
gas,  but  will  cause  asphyxia  wnen  present  in  sufficient  volume  to  interfere  with 
the  atmospheric  oxygen  in  the  performance  of  its  function.  Most  authorities 
agree  that  an  atmosphere  containing  4  per  cent,  of  CO2  and  about  16  per  cent, 
of  oxvgen  cannot  support  hfe  for  any  length  of  time,  since  the  blood  cannot 
get  enough  oxygen  for  the  needs  of  the  cells,  nor  can  the  blood  rid  itself  of  its 
CO2,  because  the  tension  of  CO2  in  the  atmosphere  exceeds  that  of  the  CO2  in 
the  blood.  Under  such  conditions  the  blood  corpuscles  cannot  excrete  it  and 
asphyxia  results.  In  addition  to  the  gases  normally  present  in  the  atmos- 
phere the  following  should  be  mentioned  as  sources  of  danger  in  mines. 

Carbon  monoxide,  CO,  also  known  as  "white-damp,"  when  present  in  the 
air  of  mines  is  the  product  of  slow  or  incomplete  combustion  of  carbon,  and 
is  chiefly  produced  during  blasting  operations  and  by  "gob  fires"  where  the 
air  is  limited.     For  symptoms  of  poisoning  see  pages  59  and  726. 

Apart  from  being  a  profound  blood  poison,  its  presence  in  fire-damp  mix- 
tures tends  to  widen  the  explosive  effects  of  fire-damp. 

The  danger  of  carbon  monoxide  even  in  small  volume  is  so  great  that 
Haldane  recommends  the  use  of  birds  and  mice  for  the  purpose  of  detecting 
harmful  quantities  of  this  gas,  as  a  protection  to  exploring  and  rescue  parties 
in  mines.  The  U.  S.  Bureau  of  Mines^  found  that  a  canary  bird  collapsed 
in  the  presence  of  between  0.20  and  0.30  per  cent,  of  carbon  monoxide,  while 
the  members  of  the  exploring  party  experienced  no  symptoms  of  distress. 
The  bird  quickly  revived  when  placed  in  better  air.  The  Bureau  of  Mines 
strongly  urges  general  adoption  of  the  bird  test  in  this  country. 

Sulphureted  hydrogen,  H2S,  may  be  found  occasionally  as  an  occluded 
gas  in  coal  seams,  and  in  mines  is  usually  the  product  of  decomposition  of 
pyrites  in  the  presence  of  moisture.  It  is  a  blood  poison,  as  it  takes  away 
the  oxyhemoglobin,  and  is  generally  recognized  by  miners  as  "stink-damp" 
on  account  of  the  odor  resembling  that  of  rotten  eggs.  When  mixed  with 
seven  times  its  volume  of  air  it  is  violently  explosive. 

Marsh  gas,  CH4,  also  known  as  fight  carbureted  hydrogen  and  methane, 
is  the  product  of  decomposition  of  carbonaceous  matter,  which  has  taken 
place  with  the  exclusion  of  air  and  in  the  presence  of  water.  It  is  one  of  the 
characteristic  occluded  gases  of  coal  mines,  and  is  not  observed  in  metaUifer- 
ous  mines.  Olefiant  gas,  C2H4,  and  ethane,  C2H6,  are  known  as  heavy  hydro- 
carbon gases  and  are  Ukewise  the  product  of  the  decomposition  of 
carbonaceous  matter  but  in  the  absence  of  water,  hence  they  contain  a 
higher  percentage  of  carbon  than  marsh  gas.  Olefiant  gas  and  ethane  are 
rarely  found  under  normal  conditions  in  coal  mines,  and  if  present  they  are 
the  result  of  a  mine  tire  or  the  intrusion  of  gas  from  a  natural  gas  well. 

Fire-damp. — The  constituents  of  fire-damp  are  methane  and  air.  It  is 
of  special  importance  as  marsh  gas,  in  the  proportion  of  i  to  13  of  air,  forms 


MINING,   QUARRYING    AND    ALLIED    INDUSTRIES  62 1 

an  explosive  mixture,  which  reaches  its  maximum  violence  when  the  propor- 
tion of  carbureted  hydrogen  is  i  to  93^^. 

After-damp. — This  term  refers  to  the  gaseous  mixture  in  mines  after 
an  explosion  of  gas.  The  chief  products  of  a  fire-damp  explosion  are  carbon 
dioxide,  watery  vapor,  nitrogen  and  CO.  When  a  large  body  of  gas  has 
been  exploded  and  the  air  of  the  mine  does  not  furnish  sufficient  oxygen  for 
the  complete  combustion  of  fire-damp,  a  large  amount  of  carbon  m6noxide 
may  be  present  in  the  after-damp.  For  like  reasons  we  may  expect  an  ab- 
normal amount  of  carbon  monoxide  in  the  air  of  mines  after  a  coal  dust 
explosion  or  during  blasting  operations.^ 

In  addition  to  carbon  monoxide,  the  nitrous  fumes  given  off  during  the 
explosion  of  dynamite,  gelignite,  roburite,  blasting  gelatine,  etc.,  doubtless 
play  an  important  role  in  the  development  of  acute  respiratory  diseases  and 
other  affections.  The  undue  prevalence  of  pneumonia  among  the  workers 
in  some  of  the  mines,  both  here  and  in  South  Africa,  may  in  part  be  due  to 
the  fact  that  exposure  to  nitrous  gases,  apart  from  engendering  pulmonary 
congestion,  also  produces  methemoglobin.  It  has  been  noted  by  Dr.  Hunt- 
ington, cited  by  Dr.  Ebright,®  that  men  engaged  in  blasting  operations  are 
inclined  to  be  irritable  and  pugnacious  and  that  it  is  unsafe  to  pick  a  quarrel 
with  them.  Dr.  Ebright  attributes  this  to  the  fact  that  alcohol  enhances 
the  toxic  effects  of  nitroglycerine,  and  in  support  cites  a  case  in  which  acute 
mania  with  homicidal  impulses  developed. 

Explosive  Conditions  in  Mines. — Among  the  causes  which  render  ex- 
plosive conditions  in  mines  possible  are  the  following:  i.  Defective  ventila- 
tion; (2)  sudden  increase  of  explosive  gases  from  falls  of  roof;  (3)  dry  coal 
dust  suspended  in  the  air;  (4)  pressure  due  to  a  heavy  blast  or  concussion 
of  the  air;  (5)  rapid  succession  of  shots  in  close  workings;  (6)  accidental  dis- 
charge of  an  explosive  in  a  dusty  atmosphere.  The  exciting  cause  may  be 
ignition  of  fire-damp,  but  much  more  frequently  it  is  the  ignition  of  fine 
coal  dust,  caused  by  a  blown-out  shot. 

Preventive  Measures. — For  the  prevention  of  fire-damp  explosions, 
safety  lamps,  electric  lights,  copious  ventilation  and  safety  rules  have  been 
found  most  efficient.  Copious  ventilation,  on  the  other  hand,  has  proved 
a  source  of  danger  by  stirring  up  fine  coal  dust  and  carrying  it  to  the  roofs, 
sides,  bars  and  props  of  the  mines,  and  thus  greatly  increasing  the  dangers 
from  coal  dust  explosions. 

This  danger  is  generally  recognized  and  recommendations  for  the  pre- 
vention of  such  catastrophes  have  been  made.  Garforth,  cited  by  Oliver,^ 
suggests  fixing  the  dust  (i)  by  water  spraying  under  high  pressure;  (2)  by 
keeping  the  roadways  free  from  dust  for  certain  lengths,  thus  creating  dust- 
less  zones;  (3)  covering  or  diluting  the  coal  dust  with  stone  dust.  Ascher 
and  others  recommend  spraying  with  calcium  and  magnesium  chlorides 
mixed  with  silicate  of  soda,  .glycerine,  water,  etc.  Thornton  advocates 
ispraying  with  soapy  water;  others  advocate  the  removal  of  coal  dust  by 


62  2        ETIOLOGY   AND   PROPHYL.\XIS    OF    OCCUPATIONAL   DISEASES 

vacuum  cleaners.  So  far  the  creation  of  dustless  zones  and  the  use  of  stone 
dust,  urged  by  Garforth,  appear  to  give  promise  of  the  most  satisfactory 
results.  Water  spraying  was  followed  by  an  increase  in  the  number  of  cases 
of  hook-worm  infection  among  the  German  miners  in  the  Valley  of  the  Ruhr. 
Prof.  Holmes,  Director  of  the  Bureau  of  Mines,^  finds  that  there  is 
little  or  no  danger  from  coal  dust  explosion  in  the  spring,  summer  and  early 
autumn  months,  as  the  warm  air  admitted  from  without,  upon  being  cooled 
by  contact  with  the  cool  walls  within,  deposits  its  moisture  and  keeps  up  a 
continuous  sweating.  During  the  cold  winter  months  it  has  been  found  that 
the  introduction  of  exhaust  steam  from  the  mine  power  plant  in  sufl&cient 
quantities  to  raise  the  temperature  of  the  entering  air,  and  at  the  same  time 
to  supply  it  with  moisture,  offers  a  simple  safeguard.  Prof.  Holmes  fully 
realizes  that  this  method,  as  well  as  spraying,  is  likely  to  favor  the  develop- 
ment and  spread  of  the  hook-worm  disease,  and  also  to  create  less  favorable 
working  conditions  as  regards  humidity  and  temperature.  But  happily 
neither  of  these  evils  has  appeared  after  an  experience  of  nearly  5  years. 

Diseases  of  Miners,  Tunnel  Workers  and  Quarrymen. — ^Lindemann's® 
German  statistics  for  1911,  based  upon  a  membership  of  357,321,  show  that 
diseases  of  the  digestive  organs  lead  the  list  in  the  order  of  frequency  with 
39,725  cases  or  11. i  per  cent.;  (2)  diseases  of  the  respiratory  organs,  28,954 
or  81  per  cent.;  (3)  neuralgia,  33,991  or  0.94  per  cent.;  (4)  acute  articular 
rheumatism,  3482  or  0.97  per  cent.;  (5)  muscular  rheumatism,  30,008  or 
0.83  per  cent.;  (6)  pneumonia,  1774  or  0.49  per  cent.;  (7)  nystagmus,  1356  or 
0.37  per  cent.;  (8)  hook-worm  disease,  11 66. or  0.32  per  cent.;  (9)  emphysema 
and  asthma,  689  or  0.19  per  cent.;  (10)  heart  disease,  449  or  0.12  per  cent. 

Miners  and  tunnel  workers  may  also  be  subject  to  compressed-air  disease, 
and  Dr.  G.  W.  Johnson^"  has  reported  42  cases  of  gas  poisoning  caused  by  the 
fumes  of  a  petroleum  motor  engine,  used  in  the  construction  of  the  Montreal 
tunnel. 

Affections  known  as  "beat  hand,"  "beat  knee,"  "beat  elbow"  are  prima- 
rily due  to  friction  of  tools  or  contact  with  hard  ground,  etc.,  causing  callosities 
of  the  skin  beneath  which  infection  may  occur,  giving  rise  to  subcutaneous 
cellulitis  of  the  hand,  over  the  patella  and  elbow.  Inflammation  of  the  syno- 
vial lining  of  the  wrist-joint  and  tendon  sheaths  is  not  uncommon. 

The  undue  prevalence  of  diseases  of  the  digestive  organs  has  no  special 
connection  with  the  occupation,  except  in  so  far  as  it  tends  to  the  consumption 
of  cold  victuals  and  of  excessive  quantities  of  cold  water  when  the  body  is 
overheated. 

Nieszytka^'^  mentions  mechanical  pressure  of  the  tool  upon  the  stomach 
and  liver,  the  ingestion  of  dust,  the  inhalation  of  sulphureted  hydrogen  and 
carbon  monoxide,  and  the  abuse  of  alcohol  as  possible  factors,  and  that  pro- 
hibition of  the  use  of  alcoholic  beverages  during  working  hours,  especially  in 
the  clay  and  stone  quarries,  has  had  a  beneficial  effect.  The  respiratory  dis- 
eases, however,  are  greatly  influenced  by  the  character  and  amount  of  dust, 


MINING,   QUARRYING   AND   ALLIED   INDUSTRIES  623 

injurious  gases,  heat  and  humidity,  abrupt  changes  in  temperature,  drafts, 
overwork,  etc.  The  gases  in  the  after-damp,  especially  carbon  monoxide 
and  nitrous  fumes,  doubtless  play  an  important  role  in  the  causation  of  acute 
pulmonary  affections.  Workers  in  quarries,  on  account  of  the  additional 
exposure  to  the  elements,  are  much  more  liable  to  pneumonia  than  miners. 
The  majority  of  chronic  respiratory  diseases  begin  as  catarrhal  affections  of 
the  upper  air  passages — bronchial  catarrh — which  may  terminate  in  or  be 
complicated  sooner  or  later  with  pneumoconiosis  (see  p.  218),  emphysema 
and  tuberculosis. 

The  character  of  dust  doubtless  plays  a  more  important  role  than  the 
amount.  In  no  other  way  can  we  explain  the  comparative  innocuity  of  coal 
dust,  the  particles  of  which  are  quite  free  from  sharp  points  and  corners. 
Dr.  Ogle,  in  the  45th  Annual  Report  of  the  Registrar  General,  has  shown  that 
coal  miners  stand  at  the  head  of  the  list  as  regards  comparative  immunity 
from  phthisis  and  other  lung  diseases  in  dust-inhaling  occupations.  On  the 
other  hand,  the  Cornish  tin  miners,  who  are  exposed  to  the  inhalation  of  a 
sharp  angular  and  most  irritant  type  of  dust,  furnish  the  largest  number  of 
cases.  This  difference  in  the  character  of  the  dust  is  also  strikingly  illus- 
trated by  our  American  statistics,  which  show  a  mortality  from  tuberculosis 
and  pneumonia  of  25.8  per  cent,  among  coal  miners,  compared  with  31.63  per 
cent,  among  metal  miners  and  43.5  per  cent,  among  copper  miners.  The 
observations  among  the  gold  quartz  miners  of  South  Africa  has  already  been 
referred  to.  Dr.  A.  J.  Lanza  of  the  U.  S.  P,  H.  S.  in  a  recent  address  before 
the  American  Public  Health  Association  directed  attention  to  the  unusual 
amount  of  pulmonary  diseases  among  the  zinc  miners  of  the  Joplin  district 
as  compared  with  similar  miners  in  southeastern  Missouri,  and  attributes 
the  difference  to  the  presence  of  large  amounts  of  flint  dust,  which  has  a  silica 
content  of  over  95  per  cent.  Nieszytka^-  states  that  salt  and  sulphur  mining, 
and  all  metal  mining  involving  exposure  to  dust  containing  lead,  predispose 
to  tuberculosis;  on  the  other  hand,  Caryophilis  reports  only  five  cases  of 
tuberculosis  among  1932  Greek  sulphur  miners.  Nieszytka  reports  that  76.5 
per  cent,  of  all  the  deaths  among  the  sandstone  workers  at  Hannover  are 
caused  by  tuberculosis  and  that  their  average  age  is  only  35.1  years.  On 
the  other  hand,  he  cites  Grab's  statistics  to  show  that  in  limestone  workers 
tuberculosis  is  the  cause  of  death  in  only  7.5  per  cent,  of  the  total  mortality, 
with  a  tuberculosis  morbidity  rate  according  to  Schlokow  of  only  2.2  per  1000. 
Koelsch^^  confirms  Grab's  statistics  with  reference  to  the  lime  and  cement 
industry  and  cites  the  statistics  of  a  German  Benefit  Society  to  show  that 
among  400  workers,  in  a  German  plaster-of-Paris  establishment,  no  cases  of 
tuberculosis  occurred  during  a  period  of  17  years,  and  that  of  40,824  deaths 
from  tuberculosis  analyzed  by  Fisac  in  Spain,  only  17  or  0.41  per  1000  occurred 
in  lime  or  gypsum,  workers.  Selkirk,'^  of  our  own  country,  was  also  unable 
to  find  a  single  case  of  phthisis  among  lime  workers,  nor  could  he  learn  of  any 
worker  in  limekilns  having  died  from  this  disease.     He  suggests  that  the 


624        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

workingman  predisposed  to  tuberculosis  might  turn  his  attention  to  lime  and 
cement  working  as  an  occupation,  and  even  hints  at  the  organization  of  lime 
works  as  a  curative  for  a  tuberculosis  colony.  All  such  statements  deserve 
painstaking  investigations.  While  it  must  be  conceded  that  lime  and  plaster 
of  Paris  belong  to  the  less  irritant  kinds  of  dust,  in  our  present  state  of  knowl- 
edge it  cannot  be  claimed  that  their  inhalation  prevents  tuberculosis  or  is  in 
any  way  a  curative  agent. 

The  tuberculosis  death  rate  among  the  workers  in  slate  quarries  in  Thur- 
ingia  amounts  to  43.1  per  cent,  and  even  to  64.3  per  cent,  among  the  slate- 
pencil  makers,  and  this  in  spite  of  the  fact  that  dust  production  is  not  spe- 
cially excessive.  It  is  also  high  among  the  slate  workers  of  Wales.  Oliver 
suggests  that  the  bad  housing  and  Hving  conditions  are  important 
factors. 

The  quarrymen  and  stonebreakers  of  the  Leipsic  Sick  Benefit  Society 
have  the  third  highest  morbidity  rate,  viz.,  1496  days  per  100  workers,  and 
the  mortahty  hazard  is  0.88  per  cent. 

The  undue  prevalence  of  rheumatic  and  neuralgic  affections  is  doubtless 
influenced  by  unfavorable  working  conditions,  such  as  heat,  humidity, 
sudden  changes,  stooped  positions,  contact  with  wet  ground,  scant  clothing, 
etc.  Hard  work,  articular  rheumatism  and  alterations  in  the  lung  tissue, 
such  as  pneumoconiosis,  emphysema,  etc.,  naturally  favor  the  development 
of  heart  lesions. 

The  cause  of  nystagmus  is  still  somewhat  obscure.  Butler^^  believes  that 
chronic  carbon  monoxide  poisoning  is  one  of  the  chief  factors.  Lindemann's 
experience  leads  him  to  conclude  that  the  muscular  strain  incident  to  an 
abnormal  position  of  the  eyeball,  and  the  glare  of  the  miner's  lamp,  are  more 
important  factors  than  defective  light,  carbon  monoxide  gas,  and  other 
suggested  causes.  He  believes  that  chronic  inflammatory  conditions  of  the 
eyes,  opacity  of  the  cornea,  visual  defects,  anaemia,  general  weakness  and 
alcoholism  also  favor  the  development  of  nystagmus,  which,  while  affecting 
between  3  and  4  per  1000  miners,  is  rarely  of  sufiicient  gravity  to  prevent 
recognition  of  a  2  to  3  per  cent,  fire-damp  in  the  flame  of  a  benzine  safety 
lamp. 

Hook-worm  disease  deserves  special  attention,  as  the  conditions  in  mines, 
with  special  reference  to  absence  of  privies,  temperature,  humidity,  exposed 
portions  of  the  skin,  and  the  eating  of  food  with  unclean  hands  favor  the 
development  and  spread  of  the  disease.  In  1904  hook-worm  infection  was 
noted  in  13,861  Westphalian  miners;  in  191 1  there  were  still  1166  cases  or 
3.26  per  1000.  In  the  meantime  an  energetic  campaign  had  been  waged 
against  the  spread  of  the  infection  by  the  erection  of  transportable  privies 
for  the  prevention  of  soil  pollution,  disinfection  of  stools  by  means  of  milk 
of  lime,  and  by  the  administration  of  thymol  for  the  destruction  of  the  para- 
site in  infected  individuals. 

The  carriers  of  infection  arc  not  permitted  to  resume  work  in  the  mines 


MINING,   QUARRYING    AND   ALLIED   INDUSTRIES  625 

until  found  free  from  worms  and  eggs  for  a  period  of  2  weeks  after  cessation 
of  medication;  a  reexamination  is  made  at  the  expiration  of  6  weeks. 

Dr.  Lanza,  in  the  address  on  the  health  hazards  of  the  metal  mining  indus- 
try already  referred  to,  states  that  hook-worm  disease  has  been  found  among 
miners  in  southern  California;  other  mining  sections  appear  to  be  as  yet 
free  from  the  infection.  Amebic  dysentery  has  been  observed  in  some  of  the 
Arizona  mining  camps,  following  the  importation  of  Mexican  labor,  and  he 
fears  that  hook-worm  may  also  gain  a  foothold  there. 

Anaemia  has  always  been  quite  prevalent  among  miners  and  at  one  time 
the  belief  that  chronic  carbon  monoxide  poisoning  and  absence  of  sunlight 
played  an  important  role  in  the  causation  of  anaemia  montana  appeared 
justified.  It  is  highly  probable,  however,  that  hook-worm  infection  and 
chronic  pulmonary  diseases  are  the  most  important  factors.  For  caisson 
disease  in  tunnel  workers  see  page  188. 

Preventive  Measures. — Commendable  progress  is  being  made  in  the 
substitution  of  machine  labor  for  hand  labor.  This,  together  with  reasonable 
hours  of  work,  diminution  in  dust  production  and  its  removal  by  exhaust 
ventilation,  will  materially  aid  not  only  in  the  prevention  of  diseases  of  the 
respiratory  and  circulatory  organs,  but  also  in  the  prevention  of  accidents 
from  explosions  of  gases  and  coal  dust.  The  general  use  of  permissible 
explosives  should  be  insisted  upon.  The  question  of  adequate  ventilation 
is  of  special  importance.  According  to  Dr.  Lanza,  in  France  the  law  limits 
the  regular  working  temperature  to  96°  dry  and  86°  wet  bulb.  In  Victoria 
and  New  Zealand  80°  wet  bulb  is  the  limit.  In  Germany  when  the  wet  bulb 
is  above  80°  the  shift  is  reduced  from  8  to  6  hours.  The  undue  prevalence 
of  rheumatic  and  neuralgic  affections  can  be  materially  checked  by  suitable 
work  suits  and  avoidance  of  abrupt  changes  in  temperature,  and  by  shower 
baths  and  change  of  clothing  upon  cessation  of  work.  Men  engaged  in 
quarries  should  be  provided  with  suitable  shelter  during  inclement  weather; 
the  employment  of  respirators  and  eye  protectors  is  clearly  indicated.  No 
effort  should  be  spared  to  improve  the  housing  and  living  conditions  of  miners 
and  quarrymen,  whose  natural  powers  of  physical  endurance  are  severely 
taxed  by  so  many  injurious  factors  connected  with  their  work. 

Stonecutters  and  Marble  Workers. — These  occupations  have  from  time 
irhmemorial  been  regarded  as  inimical  to  health  and  even  Ramazzini,  in 
the  first  book  on  Occupational  Diseases,  calls  attention  to  the  fact  that  the 
inhalation  of  the  dust  incident  to  hewing,  cutting  and  pohshing  of  marble 
or  of  stone  produces  a  troublesome  cough,  and  that  a  goodly  number  of  the 
operatives  become  asthmatic  and  consumptive.  We  know  now  that  the 
inhalation  of  mineral  dust  develops  sooner  or  later  pneumoconiosis  which 
may  eventuate  in  pulmonary  tuberculosis.  It  is  generally  held  that  the 
liability  to  diseases  of  the  respiratory  passages  is  less  in  the  case  of  paving 
stonecutters  and  slate  splitters,  and  in  the  sawing,  grinding,  polishing  and 
lathe  work  which  can  be  conducted  by  the  wet  process,  than  in  the  case  of 
40 


626        ETIOLOGY   AND   PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

monument  or  custom  work,  and  particularly  in  the  surfacing,  carving  and 
cutting  with  pneumatic  tools.  The  greatest  amount  of  dust  is  evolved  by 
the  surfacing  machines  which  are  operated  with  compressed  air.  Of  the 
various  tools  employed,  the  bushing  hammer  creates  the  finest  dust.  Un- 
fortunately, work  with  pneumatic  tools  cannot  be  done  by  the  wet  process,  as 
the  pasty  material  created  by  a  mixture  of  water  and  dust  clogs  up  the  tools. 
This  work  is  usually  done  in  large  open  sheds  or  in  the  yards,  but  even  under 
such  conditions  the  men  are  exposed  to  clouds  of  dust.  The  sawing  of  granite 
and  marble  into  slabs,  turning  in  lathes,  and  the  final  polishing  can  be  con- 
ducted by  the  wet  process;  soapstone  sawing  and  cutting  for  joints  is  fre- 
quently done  dry  and  is  attended  with  exposure  to  considerable  dust. 

The  following  is  a  condensed  extract  of  Mr.  W.  C.  Day's^^  description  of 
the  polishing  process:  The  slabs  of  stone  to  be  polished  are  placed  upon  a 
rubbing  bed  which  consists  of  a  circular  cast-iron  plate  from  8  to  15  ft.  in 
diameter  with  a  circular  opening  about  18  in.  in  the  center,  and  mounted 
upon  a  running  gear  so  that  it  may  revolve  in  a  horizontal  plane.  An 
abrading  material  such  as  sand  sometimes  mixed  with  "chilled  shot"  or 
crushed  steel,  with  a  constant  supply  of  water,  is  fed  upon  the  plate.  When 
the  process  has  gone  far  enough,  the  slabs  are  removed  to  the  emery  bed, 
which  is  similar  to  the  one  described,  fine  emery  being  used  for  abrasion. 
The  slabs  are  next  rubbed  down  by  hand  with  a  fine,  evenly  grained  sand- 
stone, known  as  "Scotch  hone,"  and  smoothed  off  with  pumice  stone.  The 
final  polish  is  put  on  by  placing  the  slabs  upon  a  buffing  bed,  which  is  similar 
to  the  rubbing  bed  but  covered  with  a  thick  specially  prepared  felt.  A  small 
amount  of  putty  powder  is  fed  to  give  a  high  polish.  The  hand  process 
consists  in  grinding  on  the  rubbing  bed  as  before,  and  then  rubbing  down  by 
hand,  successively  with  Nova  Scotia  "blue  stone,"  "red  stone,"  "Scotch 
hone"  and  pumice  stone,  after  which  it  is  glossed  with  putty  powder,  or  in 
case  of  cheaper  "onyxes"  and  common  marbles,  with  a  mixture  of  two  parts 
of  oxalic  acid  and  one  part  of  tin  oxide. 

Of  the  various  kinds  of  stone  dust  some  are  doubtless  more  injurious  than 
others.  Reference  has  already  been  made  to  the  excessive  death  rates  from 
tuberculosis  among  workers  in  sandstone  and  the  low  rates  in  limestone 
workers  in  Germany.  Hoffman^^  cites  two  observations  in  this  country 
which  apparently  corroborate  the  German  statistics  in  this  respect.  Accord- 
ing to  an  observer  of  conditions  in  the  sandstone  industry,  sandstone  cutters 
seldom  live  to  be  50  years  of  age,  and  nearly  all  of  them  die  of  lung  disease 
due  to  the  inhalation  of  mineral  dust.  A  physician  of  long  residence  in  the 
New  Bedford  Indiana  limestone  field  states  that  he  has  not  observed  very 
serious  consequences  to  result  from  employment  in  that  industry,  but  as 
justly  remarked  by  Hoffman  "all  such  observations  are  subject  to  serious 
error  in  the  absence  of  trustworthy  statistical  data  for  a  period  of  years." 

The  Inspectors  of  the  State  Board  of  Health  of  Massachusetts^^  regard 
granite  dust  more  injurious  than  marble  and  soapstone  the  least  of  all;  some 


MIXING,   QUARRYING   AND    ALLIED    INDUSTRIES  627 

varieties  of  granite  yield  a  much  finer  dust  than  others  on  account  of  differ- 
ences of  texture.  It  should  be  remembered,  however,  that  cutting  of  all  vari- 
eties of  stone  involves  exposure  to  dust,  and  that  the  character  of  the  dust, 
the  environments  under  which  the  work  is  performed,  the  social  conditions, 
such  as  housing,  etc.,  doubtless  influence  to  a  great  extent  the  liability  to 
pulmonary  affections. 

A  collective  investigation  cited  by  Roth^^  shows  that  of  every  100  deaths 
among  stonecutters,  polishers,  etc.,  86  were  due  to  diseases  of  the  lungs, 
inclusive  of  55  deaths  from  tuberculosis. 

Of  2013  stonecutters  examined  by  Sommerfeld^^  19.7  per  cent,  were 
afflicted  with  tuberculosis,  17.98  per  cent,  with  other  diseases  of  the  lungs,  and 
nearly  all  had  a  chronic  catarrh  of  the  throat  or  larj-nx.  According  to  the 
report  of  the  State  Board  of  Health  of  Massachusetts^"  of  343  deaths  which 
occurred  in  the  city  of  Quincy  among  stonecutters  during  a  period  of  16 
years  41.4  per  cent,  were  caused  by  consumption,  12  per  cent,  were  due  to 
other  diseases  of  the  lungs;  12.8  per  cent,  to  diseases  of  the  heart;  7  per 
cent,  to  violence;  and  26.8  per  cent,  to  all  other  causes. 

In  analyzing  the  statistics  of  the  towns  in  the  State  of  Vermont,  where 
most  of  the  granite  and  marble  industry  is  carried  on,  the  writer  found^^ 
that  Barre,  Montpelier,  Rutland,  Proctor,  Dorset,  Hardwick,  Bethel  and 
Ryegate,  with  a  combined  population  of  34,889,  had  a  tuberculosis 
death  rate  of  2.2  per  1000  of  population,  against  a  rate  of  1.3  for  the 
entire  State. 

Hoffman's-^  statistics  based  upon  534  deaths  among  stonecutters  from  all 
causes,  shows  that  the  principal  cause  of  death  was  tuberculosis,  amounting 
to  47.8  per  cent,  at  the  ages  between  25  and  44  years,  and  at  ages  between 
45-62  to  32.3  per  cent,  of  the  mortality  from  all  causes.  According  to  the 
recent  Ohio  Survey  by  Hayhurst,  of  163  deaths  between  1910  and  191 2, 
among  the  marble  and  stonecutters,  27.61  per  cent,  were  caused  by  pulmonary 
tuberculosis,  as  compared  with  7.13  per  cent,  in  persons  engaged  in  agricul- 
tural pursuits.  The  Leipsic  statistics  show  a  sickness  rate  for  marble  cutters 
of  1294  days  for  100  members  per  annum  and  a  mortality  hazard  of  1.27 
per  cent. 

Millstone  cutting  has  always  been  regarded  as  a  dangerous  occupation, 
with  special  reference  to  pulmonary  diseases.  This  is  due  to  the  fact  that  on 
account  of  the  very  hard  character  of  buhr-stone,  which  is  composed  of  a 
variety  of  quartz,  there  is  an  unusual  wear  and  tear  of  the  steel  tools  with 
which  the  stone  is  dressed,  and  the  men  are  exposed  to  a  combination  of  steel 
and  mineral  dust.  Oliver^^  found  very  few  old  men  in  this  industry,  and 
states  that  buhr-stone  workers  are  frequently  intemperate.  The  same  may 
be  said  of  stone  workers  in  general,  who  attribute  the  habit  to  the  dryness 
of  the  throat  caused  by  the  lodgment  of  dust.  It  must  be  conceded  that  all 
dust-producing  occupations  are  predisposing  factors  to  the  alcoholic  habit, 
especially  when  the  employer  makes  no  attempt  to  furnish  pure  water,  and 


628         ETIOLOGY    AND    PROPHYLAXIS    OF    OCCUPATIONAL    DISEASES 

when  the  regulations  for  the  prevention  and  removal  of  dust  are  totally 
ignored. 

Apart  from  the  danger  of  dust  inhalation  the  liability  to  accidents  is  not 
inconsiderable  in  all  stonecutting  operations,  injuries  to  the  eyes  from  flying 
chips  and  fragments  of  steel  from  implements  are  especially  common.  Rheu- 
matic affections  and  colds,  as  a  result  of  exposure  are  also  quite  common. 
The  work  is  very  laborious  and  none  but  able-bodied  men  should  enter  the 

trade. 

Preventive  Measures. — All  the  precautions  mentioned  in  the  preceding 
section  for  the  protection  of  quarrymen,  such  as  wet  processes,  general  cleanli- 
ness and  copious  downward  exhaust  ventilation,  use  of  goggles  and  respira- 
tors are  applicable  for  stonecutters. 

The  Clay  Products  Industry. — ^The  brick  and  tile  industry  includes  the 
manufacture  of  building  bricks,  fancy  and  ornamental  bricks,  vitrified  pav- 
ing brick,  drain  tile  and  sewer  pipe.  During  the  last  U.  S.  census  76,528 
persons,  including  81  women  and  1270  persons  under  16  years  of  age,  were 
employed  in  this  industry. 

The  preliminary  work,  such  as  grinding  and  mixing  of  clay  involves  ex- 
posure to  dust,  also  to  the  elements  and  to  wet  processes,  while  in  the  vicinity 
of  the  kilns,  there  is  more  or  less  exposure  to  excessive  heat,  sudden  changes  in 
temperature,  drafts  and  to  the  inhalation  of  CO,  CO2,  and  of  sulphurous  acid. 

Instances  of  carbon  monoxide  poisoning  have  occurred  in  men  entering 
the  kilns  for  the  purpose  of  filling  or  emptying,  also  during  the  burning  process, 
by  the  escape  of  gas  from  defective  kilns  and  flues.  Rambousek  cites  the  case 
of  a  worker  who  was  about  to  fill  a  kiln,  and  upon  opening  the  furnace 
door  was  overcome  by  large  volumes  of  CO,  which  proved  fatal,  in  spite  of 
efforts  at  resuscitation. 

The  German  statistics,  cited  by  Gottschalk^^show  that  nearly  21  per  cent. 
of  all  the  sickness  is  caused  by  muscular  rheumatism,  mostly  lumbago  which 
is  frequently  accompanied  by  sciatica  and  other  neuralgia.  Pneumonia  and 
pleurisy  contributed  5.4  per  cent.,  and  colds  and  catarrhal  affections  of  the 
respiratory  organs  18.1  per  cent,  of  the  general  morbidity.  The  catarrhal 
affections  are  to  a  considerable  extent  induced  by  inhalation  of  dust,  and 
German  authors  have  found  a  sufficient  number  of  "clay  lungs"  to  justify 
the  term  aluminosis.  During  the  winter  months  influenza  contributes  an 
additional  10  per  cent,  to  the  morbidity  rate.  It  is  evident  that  the  undue 
prevalence  of  diseases  of  the  respiratory  organs  paves  the  way  for  tuberculosis. 
•12.3  per  cent,  of  the  morbidity  was  caused  by  diseases  of  the  digestive  system, 
probably  due  to  sudden  changes  in  temperature,  improper  food,  and  the  per- 
nicious habit  of  cold  drinks  while  the  body  is  overheated. 

On  account  of  soil  pollution  caused  by  primitive  habits  at  the  clay  banks 
there  is  also  a  certain  amount  of  danger  from  infection  with  the  hook-worm, 
the  small  intestinal  round  worm  and  typhoid  organisms.  Varicose  veins 
and  ulcers  arc  not  uncommon. 


illXIXG,    QUARRYIXG    AND    ALLIED    IXDUSTRIES  629 

Callosities  of  the  hands,  as  a  result  of  hard  work,  and  eczema  of  the  hands 
and  wrists  from  exposure  to  dust,  dirt  and  moisture  are  frequently  observed. 
Most  of  the  glazing  is  done  by  the  addition  of  salt.  The  danger  from  lead 
poisoning  in  the  manufacture  of  fancy  ornamental  and  enameled  bricks, 
due  to  the  employment  of  glazes  containing  lead,  will  be  referred  to  in  con- 
nection with  the  pottery  industry. 

Preventive  Measures. — The  hygiene  of  this  industry  has  been  very 
much  neglected  and  this  is  especially  true  with  reference  to  clean,  decent 
quarters  and  sanitary  conveniences  for  unmarried  employees,  and  pure 
drinking  water.  Persons  engaged  in  wet  work  should  wear  rubber  boots 
and  aprons.  Dust  production  should  be  reduced  to  a  minimum.  The  men 
employed  about  the  brick  kilns  should  wear  suitable  clothing  and  protect 
their  eyes  from  exposure  to  intense  heat  and  light,  and  should  receive  in- 
structions how  to  avoid  injurious  gases.  Washing  faciUties  before  each  meal, 
and  facilities  for  a  full  bath  and  change  of  clothing  upon  cessation  of  work, 
should  be  provided. 

The  Pottery,  Terra  Cotta  and  Fire  Clay  Product  Industry. — The  chief 
products  of  this  industry  are  stoneware,  earthenware,  porcelain  ware,  fire- 
brick and  terra-cotta  products. 

During  the  last  U.  S.  census  there  were  61,922  persons  engaged  in  this 
industry  of  whom  56,168  were  wage  earners,  inclusive  of  7000  females  and 
816  children  under  16  years  of  age. 

The  ordinary  stoneware  and  earthenware  is  usually  made  of  common 
clay.  For  the  better  grades  of  goods,  china  clay  or  calcined  bone  are  added; 
and  for  the  still  higher  grades  of  porcelain  a  mixture  composed  of  very  fine 
clay,  calcined  bone  and  feldspar  is  used.  The  most  expensive  ware  like 
Limoge  porcelain  is  made  from  very  fine  white  clay  peculiar  to  that  section. 
The  removal  of  the  dififerent  clays  from  stock  bins,  the  crushing,  grinding, 
mixing  and  sifting  processes,  and  especially  the  process  known  as  "flint  dust 
making"  are  attended  with  the  evolution  of  large  amounts  of  dust. 

There  is  also  more  or  less  exposure  to  plaster-of-Paris  dust  in  the  manu- 
facture of  moulds  for  forms  for  china,  art  ware,  etc. 

The  chief  factors  inimical  to  health  in  the  so-called  "slip  houses"  are 
dust,  heat,  fatigue  and  dampness  from  faulty  floor  drainage,  leaky  vats  and 
slip-containing  machines  and  the  presence  of  wet  clay  under  foot. 

Sagger  Making. — This  process  which  consists  in  shaping,  repairing, 
baking  and  finishing  of  clay  containers  in  which  the  pottery  ware  is  subse- 
quently baked,  and  involves  similar  hazards,  and  also  the  risk  of  lead  poison- 
ing, from  the  red  lead  solution  with  which  the  inside  of  the  saggers  are  painted. 
The  Ohio  Survey  disclosed  four  cases  of  lead  poisoning  among  20  workers 
in  this  branch. 

Bisque  Making. — In  this  department  the  clays  previously  prepared  in 
the  "slip'"  house  are  shaped  on  plaster-of-Paris  moulds  and  potter's  wheels. 
In  tile  and  procelain  factories  this  work  is  done  by  machines  in  so-called 


630        ETIOLOGY   AND   PROPHYL.AJCIS    OF    OCCUPATIONAL    DISEASES 

press  rooms.  After  the  ware  is  shaped,  it  is  carried,  usually  by  boys,  into 
the  drying  kilns,  located  in  the  rear  of  the  workers.  This  process  involves 
exposure  to  dust,  heat  and  fumes  from  the  baking  ovens,  unless  efficient 
exhaust  ventilation  is  provided. 

Glaze  Mixing. — In  order  to  render  clay  products  impervious,  and  to  secure 
a  polished  surface,  they  are  dipped  into  a  Hquid  glaze  containing  finely  ground 
clay  and  flint  and  more  or  less  white  carbonate  or  red  oxide  of  lead.  Some 
of  the  glazes  do  not  contain  lead,  but  most  of  them  do,  and  when  used  there 
is  naturally  considerable  exposure  to  lead  dust.  Of  865  cases  of  lead  poisoning 
which  occurred  between  1901  and  1909,  in  the  potteries  of  Great  Britain, 
788  were  contracted  in  glaze  processes,  51  in  decorative  processes,  and  26  in 
unclassified  processes. ^^ 

Glaze  Dipping. — After  drying  or  bisqueting,  and  sometimes  even  in  the 
green  state,  the  ware  is  dipped  into  a  glaze  solution,  or  the  solution  is  applied 
by  means  of  a  brush  or  sponge.  The  glazes  used  for  porcelain,  stoneware, 
and  some  tiles  contain  usually  no  lead.  The  colored  glazes  are  rich  in  lead 
and  the  majority  of  glazes  contain  lead  in  an  unfritted  form,  which  is  de- 
plorable as  "fritted"  lead,  which  is  a  fixed  compound  with  borax  and  sihca, 
is  less  soluble  and  hence  less  dangerous.  The  dipping  is  generally  done  by 
hand,  although  recently  dipping  machines  specially  adapted  for  tiles  and 
other  regular  pieces  are  employed  and  have  reduced  the  handling  of  glazes 
very  greatly,  and  practically  obviated  the  necessity  of  "fettling"  and  clean- 
ing of  the  glaze  from  the  edge  of  the  tile.  The  process  of  "fettling"  consists 
in  the  removal  of  superfluous  glaze  from  the  ware  prior  to  placing  it  in  the 
glost  kiln,  but  refers  more  especially  to  the  removal  of  Httle  projections  by 
means  of  a  small  steel  knife,  and  other  finishing  processes,  such  as  rubbing, 
sanding  and  dressing  after  the  ware  leaves  the  kiln. 

After  glazing,  the  ware  is  placed  in  saggers  and  fired.  Ordinary  terra- 
cotta or  stoneware  is  dipped  and  fired  but  once,  but  most  of  the  other  ware  is 
fired  twice.  In  some  branches  the  glaze  is  applied  to  already  partly  glazed 
ware  in  the  form  of  lead  enamel  dust,  by  means  of  a  cotton  pad;  this  method, 
known  as  "ground  laying,"  is  dangerous  and  has  been  to  a  great  extent  re- 
placed by  the  aerographing  process.  For  roof  tiles  and  bricks  the  glaze, 
if  used  at  all,  is  usually  poured  on,  or  applied  by  means  of  a  brush.  The  last 
two  methods  are  sloppy  and  dangerous  because  the  liquid  is  liable  to  splash 
over  the  hands,  clothing,  floor,  etc.  Kaup^^  reports  that  in  some  roof-tihng 
establishments  nearly  all  of  the  workers  suffer  from  lead  poisoning. 

The  work  in  or  about  the  kilns  involves  exposure  to  excessive  heat,  coal 
gas,  dust,  abrupt  changes  in  temperature,  and  lead  poisoning.  The  Ohio 
Survey  discloses  about  35  cases  of  lead  poisoning  among  the  1220  workers 
around  the  bisque  and  glost  kilns.  The  chief  risk  came  from  handling  the 
ware  upon  which  the  glaze  had  just  been  dried  and  from  which  it  could  be 
wiped  off  Hke  flour;  in  some  instances,  especially  in  art  and  colored  ware,  the 
dust  contained  50  per  cent,  of  lead. 


MINING,   QUARRYING   AND    ALLIED    INDUSTRIES  63 1 

Decorating  Department. — I'he  decorative  processes  may  be  carried  on 
before  or  after  the  glaze  is  applied  and  in  some  instances  the  glaze  itself  is 
colored.  So  for  example,  Rockingham  ware  is  glazed  with  a  dip  containing 
manganese,  which  results  in  a  brownish  or  plum  colored  finish,  and  jet  ware 
is  dipped  in  a  glaze  containing  cobalt  which  imparts  the  jet  black  finish. 
Since  cobalt  is  obtained  from  arsenical  ores  there  is  some  danger  from  arsen- 
ical poisoning.  Most  of  the  decorating  processes  are  carried  on  by  females 
and  weaklings  and  consist  in  the  laying  on  of  lithographic  transfers  by  means 
of  sizing  with  turpentine,  stamping  on  impressions,  "lining"  with  gold  stripes 
and  gilding,  color  spraying,  hand  painting,  etc.  The  employment  of  lead 
containing  pigments,  such  as  chrome  yellow,  nitrate  of  lead  or  red  lead, 
whether  applied  by  brush,  the  aerograph  or  decalcomania,  naturally  involves 
exposure  to  lead  poisoning.  The  Ohio  Survey  disclosed  three  cases  of  lead 
poisoning,  one  suspected  case  of  arsenic  poisoning  and  one  case  from  benzine 
varnish  poisoning. 

While  cases  of  plumbism  in  decorative  work  are  now  less  frequent,  the 
sedentary  habits  and  unfavorable  working  conditions  predispose  to  neuras- 
thenia, diseases  of  the  respiratory  and  digestive  organs,  ocular  defects  aad  in- 
flammatory conditions  of  the  eyes  from  exposure  to  turpentine.  The 
danger  from  dust  inhalation  in  the  ceramic  industry  is  plainly  revealed  by 
the  undue  prevalence  of  respiratory  diseases,  which  according  toHolitscher's^^ 
German  statistics  were  the  cause  of  death  in  72.8  per  cent,  of  the  potters, 
and  in  62.4  per  cent,  of  the  decorators.  Hoffman's  American  Industrial 
statistics  show  that  47.9  per  cent,  of  pottery  workers  perish  from  respiratory 
diseases,  inclusive  of  33.1  per  cent,  from  tuberculosis.  Rheumatic  and  neu- 
ralgic affections  and  obstinate  forms  of  eczema  are  not  uncommon.  Cases  of 
lead  poisoning  are  still  unduly  prevalent,  especially  in  this  country,  and  in  the 
smaller  establishments  and  home  industries  of  Europe.  Chyzer,^*  cited  by 
Rambousek,  refers  to  the  conditions  in  Hungary  where  members  of  the  family 
contract  the  disease  from  the  dust  in  the  living  rooms,  which  was  found  to 
contain  from  0.5  to  8.7  per  cent,  of  lead.  The  degree  of  danger  depends  upon 
the  amount  of  lead  used,  which  varies  from  10  to  24  per  cent,  in  the  glaze 
fluxes,  and  from  60  to  80  per  cent,  in  the  enamel  colors  for  decorative  purposes. 

Oliver^^  and  Thorpe,  who  investigated  the  subject  of  lead  poisoning  in  the 
potteries  of  Great  Britain,  came  to  the  conclusion,  as  early  as  1899,  that  by 
far  the  greater  amount  of  earthenware  can  be  glazed  without  lead,  and  that 
in  certain  branches  of  the  industry,  in  which  lead  is  indispensable,  it  should  be 
used  in  the  form  of  a  fritted  double  silicate.  It  has  been  found  that  the  danger 
can  be  materially  reduced  by  using  only  8  per  cent,  of  carbonate  of  lead  in  the 
form  of  a  " double  fritted  silicate"  instead  of  the  older  method,  in  which  from 
13-24  per  cent,  of  lead  carbonate  was  employed.  The  English  authorities 
determined  that  no  glaze  should  be  used  which  upon  shaking  for  an  hour  with 
1000  times  its  weight  of  a  0.25  per  cent,  watery  solution  of  hydrochloric  acid 
revealed  more  than  5  per  cent,  of  its  dry  weight  of  lead  monoxide.     The 


632         ETIOLOGY    AND    PROPHYLAXIS    OF    OCCUPATIONAL    DISEASES 

fruits  of  this  splendid  work  are  shown  by  the  fact  that  in  1898  Great  Britain 
had  still  457  cases  of  lead  poisoning  among  pottery  workers,  and  in  1908  only 
58  cases.  Unfortunately,  we  have  not  profited  by  this  lesson  to  any  consid- 
erable extent,  for  Dr.  Alice  Hamilton's^*^  investigations  show  that  while 
Great  Britain  in  1910  had  only  77  cases  in  a  force  of  6865  workers,  in  191 1  we 
had  144  cases  in  a  force  of  1500.  Nothing  should  be  permitted  to  stop  the 
campaign  for  leadless  glazes,  and  since  it  has  been  shown,  as  pointed  out  by 
Oliver, ^^  that  the  enameled  bricks  used  in  Babylon  522  B.  C.  and  the  decora- 
tive tiles  in  Egypt,  did  not  contain  lead,  it  is  hoped  that  chemistry  and 
technical  skill  will  sooner  or  later  solve  the  problem. 

Preventive  Measures. — While  much  of  the  potter's  work  is  with  moist 
materials,  it  is  evident  that  the  handling  of  all  dry  and  fired  products,  and  the 
grinding  and  mixing  of  lead  compounds  of  glazes,  involves  exposure  to  dust, 
which  should  be  reduced  to  a  minimum  by  moist  methods.  Exhaust  venti- 
lation is  important  in  all  dusty  processes  such  as  fettling  and  pressing  of 
tiles,  bedding  and  flinting,  brushing  and  scouring  of  biscuit  ware.  Exhaust 
drafts  are  especially  needed  in  the  dusty  lead  processes,  such  as  mixing  and 
grinding  of  lead  compounds,  aerographing,  color  dusting,  and  in  ware  cleaning. 
Absolute  cleanliness  of  the  workshops,  cement  or  impervious  floors,  frequently 
washed,  proper  air-space,  good  general  ventilation,  and  special  lunch  rooms  are 
important.  Suitable  work  suits  and  caps,  ablutions  before  meals,  baths  and 
change  of  clothing  upon  cessation  of  work,  and  monthly  medical  inspection  of 
workers  exposed  to  lead  processes  should  be  insisted  upon. 

Lime  Burning. — The  risks  incident  to  the  quarrying  of  limestone  have 
been  referred  to  and  also  some  interesting  statistical  data  in  reference  to  the 
comparative  danger  of  lime,  plaster  of  Paris  and  other  mineral  dusts  have 
been  presented.  Rossle's^^  recent  investigations  tend  to  show  that  workers 
in  the  lime,  cement,  procelain  and  glass  industries  have  relatively  favorable 
mortality  rates  from  tuberculosis.  The  kilns  are  generally  loaded  from  a 
car,  operated  by  cable  from  the  top  of  the  kiln  platform,  and  the  dumping 
involves  exposure  to  dust  and  more  or  less  CO2  from  the  open  kilns.  During 
the  roasting  process  there  is  exposure  to  excessive  heat  and  escaping  gases, 
while  the  unloading  from  the  false  bottom  of  the  kiln  and  the  subsequent 
grinding  and  packing  of  the  lime,  unless  a  good  suction  system  is  in  operation, 
are  naturally  very  dusty  operations.  As  a  result,  inflammatory  affections 
of  the  skin,  eyes  and  of  the  upper  air  passages  are  not  infrequent. 

Meerschaum,  also  known  as  sepiolite,  is  a  soft  white  hydrous  magnesium 
clay,  containing  silica,  and  when  dry  it  will  float  on  water.  It  is  chiefly  used 
for  carving  tobacco  pipes  and  cigar  holders  and  the  dust,  like  that  of  talc 
and  soapstone,  is  a  frequent  cause  of  chronic  diseases  of  the  respiratory 
passages. 

Mica.— This  is  a  mineral  of  widely  varying  chemical  composition,  but  is 
essentially  composed  of  silicates  of  aluminum  and  an  alkah,  such  as  potassium, 
sodium  or  lithium.     The  mineral  spHts  easily  into  thin  flexible  colorless  trans- 


MINING,    QUARRYING    AND    ALLIED    INDUSTRIES  633 

parent  plates  or  scales,  known  as  isinglass,  and  is  used  for  a  number  of  pur- 
poses where  glass  could  not  resist  the  effects  of  heat.  In  the  powdered  form 
it  is  employed  in  the  manufacture  of  a  giant  powder,  and  on  account  of  the 
gUstering  character  of  the  dust  it  is  largely  used  for  decorative  purposes, 
chiefly  in  the  manufacture  of  wall  paper,  illuminated  designs,  postal  cards, 
etc.,  and  is  doubtless  a  frequent  cause  of  inflammatory  conditions  of  the  eyes 
and  air  passages. 

Cement  Workers. — The  manufacture  of  Portland  cement  varies  in  differ- 
ent countries.  The  raw  materials  are  clay  with  flint  and  lime.  In  England 
where  chalk  is  plentiful  this  is  used  in  connection  with  some  material  con- 
taining silica  and  alumina,  such  as  selected  clay  or  river  mud.  The  raw 
materials  are  mixed  in  certain  proportions  and  ground  together  to  the  con- 
sistency of  liquid  mud.  The  excess  of  moisture  is  driven  off  by  heat,  and  the 
residue  is  dried  in  ovens  at  a  high  temperature.  The  preliminary  process, 
while  sloppy,  is  not  dusty  work,  but  the  subsequent  grinding  between  rollers 
and  the  sacking  and  packing  of  the  product  is  an  extremely  dusty  process. 
According  to  Koelsch^^  and  other  German  authors  catarrhal  affections  and 
diseases  of  the  respiratory  organs  constitute  from  30  to  40  per  cent,  of  all  the 
sickness.  Diseases  of  the  eyes,  and  ears,  impacted  ear  wax,  ulceration  of  the 
nose  with  perforation  of  the  nasal  septum,  and  eczema,  or  cement  itch,  are 
also  quite  common.  Hoffman's  Industrial  Insurance  statistics  show  that 
47.7  per  cent,  of  the  cement  workers  in  this  country  perish  from  diseases  of 
the  air  passages,  inclusive  of  19.3  per  cent,  from  tuberculosis.  The  Leipsic 
Sick  Benefit  Society  records  indicate  that  cement  mixers  and  hod  carriers 
have  a  very  high  morbidity  rate,  viz.,  1358  days  of  sickness  per  annum  per 
100  members. 

Preventive  Measures. — Wittgen^'*  has  made  a  gratifying  report  upon  the 
results  attained  in  German  cement  works  by  removal  of  dust.  He  points  out 
that  respiratory  diseases  have  been  reduced  fully  one-third  within  a  period 
of  5  years  after  the  installation  of  exhaust  ventilation,  and  the  number 
of  days  lost  by  sickness  has  been  reduced  from  2742  to  812  days  per 
annum,  which  means  a  decided  improvement  in  the  general  health  of  the 
operatives. 

Asphalt  Workers. — Asphaltum,  also  known  as  mineral  pitch  or  hard  bi- 
tumen, is  an  amorphous  brownish-black  combustible  mixture  of  different 
hydrocarbons,  and  is  obtained  in  a  natural  state  from  superficial  deposits  in 
various  parts  of  the  world.  The  same  name  is  applied  to  the  pitch  or  residue 
of  coal  tar.  The  natural  asphalt  is  chiefly  used  in  the  construction  of  asphalt 
pavements  and  waterproof  roofing  and  the  product  derived  from  coal  tar 
is  used  for  the  same  purpose,  and  also  in  the  manufacture  of  roofing  paper, 
metal  paints  and  varnishes,  artificial  fuel  (briquets),  etc.  The  grinding  of 
asphalt  gives  rise  to  large  quantities  of. dust,  which  may  cause  serious  af- 
fections of  the  cornea.  The  fumes  arising  from  the  melting  pots  are  liable 
to  produce  inflammatory  conditions  of  the  eyes  and  respiratory  passages, 


634        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

and  a  peculiar  yellowish  eruption  of  the  skin.  Open  pans  should  be  avoided 
and  Leymann  recommends  that  the  fumes  should  be  carried  into  a  furnace, 
or  absorbed  by  a  condenser  charged  with  oil. 

Brick  and  Stone  Masons.— Ascher^^  reports  that  among  5695  masons 
belonging  to  the  Berlin  Sick  Insurance  Companies,  there  were  2 181  or  38.2 
per  cent,  cases  of  sickness.  The  mortaUty  rate  from  respiratory  diseases 
inclusive  of  consumption  was  53  per  cent.,  against  46.1  per  cent,  in  the  general 
population  over  15  years  of  age.  The  mortality  from  diseases  of  the  heart, 
digestive  tract,  kidneys  and  bladder,  is  also  excessive.  Pneumonia  is  most 
frequent  in  the  helpers. 

Hoffman's^*^  Industrial  Insurance  statistics,  based  upon  1647  deaths 
among  masons  from  all  causes,  show  a  mortahty  rate  of  31.1  per  cent,  from 
respiratory  diseases,  inclusive  of  17.7  per  cent,  from  tuberculosis.  The  death 
rate  from  urinary  diseases  was  13  per  cent.;  from  heart  diseases  10. i  per  cent. 
and  from  accidents  9  per  cent.  The  German  accident  rate  for  journeymen 
was  3.8  per  cent,  and  for  apprentices  6  per  cent.  The  Leipsic  Sick  Benefit 
records  show  a  sickness  rate  of  777  days  per  100  masons  and  a  mortality 
hazard  of  0.70  per  cent. 

Dust  and  exposure  to  the  elements  are  important  predisposing  causes  to 
respiratory  diseases,  and  the  sloppy  character  of  work  is  conducive  to  rheu- 
matic and  neuralgic  affections,  while  lime  and  mortar  accounts  for  the  undue 
frequency  of  eczema  of  the  hands  and  wrists. 

Preventive  Measures. — Accidents  should  be  prevented  by  proper  con- 
struction of  scaffold  and  education  of  apprentices.  Bricks  and  stones  should 
be  moistened  to  diminish  dust  inhalation.  Cleanly  habits  and  the  applica- 
tion of  cold  cream  or  vaseline  will  aid  in  the  prevention  of  skin  affections  inci- 
dent to  cement  and  mortar  work. 

The  erection  of  sheds,  so  as  to  provide  shelter  against  cold  or  storms, 
facilities  for  warming  the  meals,  ablutions  and  change  of  clothing  is  clearly 
indicated. 

Plasterers.— Plasterers,  like  bricklayers  and  cement  workers,  are  ex- 
posed to  unfavorable  working  conditions,  such  as  damp  air,  and,  in  certain 
stages  of  the  work,  to  inhalation  of  large  amounts  of  dust  containing  lime 
and  plaster  of  Paris.  If  open  charcoal  fires  (salamanders)  are  used  for  dry- 
ing purposes,  there  is  danger  from  coal  gas.  Opinions  differ  as  to  injurious 
character  of  lime  dust;  some  authors  contend  that  tuberculosis  is  less  frequent 
among  lime  and  cement  workers  than  in  other  dusty  occupations.  Hoffman's 
Industrial  Insurance  statistics  show  that  of  577  deaths  among  plasterers, 
136  or  23.6  per  cent,  were  caused  by  consumption;  the  degree  of  frequency 
was  above  the  average  at  all  ages  under  65,  and  especially  at  ages  between 
25  to  34.  The  mortality  from  pneumonia  and  other  respiratory  diseases 
was  1 6. 1  per  cent.,  making  a  combined  death  rate  of  39.7  per  cent,  from  dis- 
eases of  the  respiratory  organs.  The  Leipsic  Sick  Benefit  records  show  a 
sickness  rate  of  738  days  per  100  plasterers,  and  a  mortahty  hazard  of  0.46 


MINING,    QUARRYING    AND    ALLIED    INDUSTRIES  635 

per    100.     Similar   conditions   would   probably   be  revealed  among   white- 
washers  if  separate  statistics  were  available. 

Preventive  Measures. — It  is  important  that  dust  production  should  be 
reduced  to  a  minimum,  and  that  the  general  precautions  recommended  for 
masons  and  cement  workers  should  be  adopted. 

Paperhangers. — This  occupation,  especially  the  process  of  scraping 
the  walls  for  the  removal  of  old  paper,  involves  considerable  dust  production, 
and  possibly  also  exposure  to  lead  and  arsenical  poisoning  if  the  wall  paper 
happens  to  contain  such  toxic  color  pigments.  A  number  of  cases  of  arsenical 
poisoning  have  been  recorded.     (See  page  4.) 

There  is  likewise  some  danger  if  the  room  has  been  occupied  by  infectious 
patients,  and  disinfection  has  been  neglected. 

These  risks  would  be  more  pronounced  if  the  walls  were  not  previously 
moistened,  but,  even  when  this  is  done,  the  subsequent  pointing  up  and 
sandpapering  of  rough  surfaces  results  in  dust  production.  Hofifman's 
Industrial  Insurance  statistics  show  that  of  319  deaths  among  paperhangers 
107  or  33.5  per  cent,  were  caused  by  consumption  and  ii.i  per  cent,  from 
other  diseases  of  the  lungs,  making  a  combined  rate  of  44.6  per  cent,  from 
diseases  of  the  respiratory  organs,  against  a  normal  expected  proportion  of 
23.6. 

Preventive  Measures. — Wet  processes  for  wall  scraping,  use  of  respirators 
in  all  dusty  work.  Personal  cleanliness  and  all  the  precautions  recommended 
against  lead  and  arsenical  poisoning. 

Emery  and  Corundum. — Emery  and  corundum  wheels  are  employed  as 
an  abrading  material,  for  grinding  and  polishing  metals,  stone,  glass,  etc., 
and  the  manufacture  and  use  of  these  materials  doubtless  plays  an  important 
role  in  the  development  of  pneumoconiosis.  Emery  is  derived  from  emery 
rock,  imported  from  Smyrna  and  the  Island  of  Naxos,  and  is  an  anhydrous 
oxide  of  aluminum,  containing  flint,  silica,  and  a  small  amount  of  magnetite 
or  hematite. 

Corundum  is  also  a  very  hard  granular  variety  of  oxide  of  aluminum. 
The  crushing  and  grinding  of  either  of  these  materials,  although  carried  on 
in  inclosed  machinery,  involves  more  or  less  exposure  to  a  very  fine  and  ex- 
tremely irritating  dust.  The  wheels  and  stones  of  different  sizes  are  made 
from  the  powdered  rocks,  mixed  with  one  or  more  of  various  binding  materials, 
such  as  clay,  glue,  shellac,  India  rubber,  oil,  sulphur,  and  silicate  of  soda. 
The  mixture  is  placed  in  a  mould  and  subjected  to  hydraulic  pressure.  The 
mixture  with  clay  is  fired  in  kilns  and  the  resulting  product  is  said  to  be  much 
harder  than  when  other  binding  substances,  such  as  shellac  or  glue,  are  used; 
but  the  latter  binders  are  more  elastic  and  less  likely  to  break.  In  order  to 
guard  against  the  possibility  of  breakage,  brass  wire  webbing  is  inserted  to 
prevent  fragmentation  and  resulting  injuries.  All  wheels  are  or  should  be 
finally  tested  in  a  metallic  compartment  at  an  exceedingly  high  rate  of  speed, 
over  7000  revolutions  a  minute,  and  those  which  pass  the  test  without  break- 


636         ETIOLOGY   AND    PROPHYL.A.XIS    OF    OCCUPATIONAL    DISEASES 

ing  may  be  considered  safe.  The  industry  involves  not  only  exposure  to  a 
very  irritant  dust,  but  also  to  lead  from  the  babbit  metal  employed  in  fitting 
the  wheels  to  spindles. 

Oliver"  states  that  since  the  introduction  of  the  emery  wheel  in  the 
Sheffield  cutlery  industry,  the  cutlers  as  a  class  have  become  even  more 
unhealthy  than  they  were  in  previous  years.  The  Inspectors  of  the  Massa- 
chusetts State  Board  of  Health^*  report  that,  while  the  great  majority  of 
the  employees  in  this  industry  appear  to  be  well  and  strong,  "a  notable 
proportion  present  a  pale  and  sickly  appearance." 

Preventive  Measures. — -The  manufacture  and  use  of  emery  or  corundum 
wheels  is  doubtless  dan'gerous  to  health,  and  should  be  safeguarded  by  re- 
ducing dust  production  to  a  minimum  and  adequate  exhaust  ventilation. 

Emery  and  Sandpaper  Making. — ^This  occupation  involves  exposure  to 
the  inhalation  of  considerable  quantities  of  emery  powder  and  sand,  derived 
from  "garnet,"  which  is  a  line  variety  of  gravel,  obtained  in  this  country  in 
the  Adriondacks.  This  gravel  is  ground,  sifted,  and  graded,  by  machinery, 
and  spread  on  paper  covered  with  glue  and  the  product  is  dried  over  steam 
pipes. 

Preventive  Measures. — Great  care  should  be  exercised  to  diminish  dust 
production  to  a  minimum,  possibly  by  the  employment  of  moist  processes 
in  the  grinding,  sifting  and  grading  processes,  for  it  is  reported  by  the  In- 
spectors of  the  State  Board  of  Health  of  Massachusetts  that  in  spite  of  the 
working  of  a  48-in.  exhaust  fan,  to  which  the  pipes  are  connected,  there  was 
a  great  deal  of  fine  dust  in  the  air.  Workm-en  are  urged  to  wear  respirators, 
but  it  is  extremely  doubtful  whether  the  inhalation  of  very  fine  dust  is  thus 
prevented. 

Diamond  Cutters  and  Polishers  of  Precious  Stones. — This  industry  is  to  a 
great  extent  centered  in  a  few  cities  of  continental  Europe,  notably  Amsterdam, 
Antwerp  and  Oldenburg.  There  are  only  about  400  men  employed  in  the 
diamond-cutting  shops  of  New  York  as  compared  with  gooo  in  Amsterdam. 
The  rough  diamond  is  usually  cut  by  another  diamond  and  is  then  embedded 
in  a  mass  of  molten  metal,  composed  of  about  60  parts  of  lead  and  40  parts  of 
tin,  to  which  a  handle  is  attached.  The  same  method,  although  with 
variable  proportions  of  the  alloy,  is  also  employed  with  other  precious  stones, 
and  greatly  facilitates  the  polishing  process,  which  is  done  by  hand,  but 
mostly  by  means  of  rapidly  rotating  small  iron  wheels  or  leaden  discs.  In 
either  case  there  is  exposure  to  dust  and  lead,  and  the  danger  from  lead  poi- 
soning is  all  the  more  pronounced  if  revolving  lead  discs,  or  a  lead-containing 
grinding  powder,  are  used.  Some  authors  still  maintain  that  during  the  melt- 
ing of  the  alloy  there  is  also  exposure  to  lead  fumes,  but  this  is  an  evident 
misapprehension,  as  the  volatilizing  point  of  lead  is  far  above  the  fusing 
point.  The  "setters"  who  prepare  the  diamond  or  gem  for  the  cutter  by 
soldering  are,  however,  exposed  to  coal  gas  when  charcoal  fires  are  used  to 
prepare  the  solder. 


MIXING,    QUARRYING    AND    ALLIED    INDUSTRIES  637 

Tracy,  cited  by  Hoffman, ^^  found  73.5  per  cent,  of  the  setters  in  Coster's 
factory  at  Amsterdam  pale  and  anaemic;  57  per  cent,  had  palpitation,  giddi- 
ness, precordial  distress;  56  per  cent,  chronic  headache;  36  per  cent,  asthma, 
etc.;  90  per  cent,  had  phthisis,  and  30  of  90  men  examined  showed  traces  of 
lead  poisoning.  Oliver^''  reports  that  wrist-drop  and  colic  are  the  prevailing 
forms  of  plumbism. 

The  same  danger  is  observed  in  the  cutting  and  polishing  of  other  precious 
stones,  which  industry,  in  some  parts  of  Bohemia,  is  not  infrequently  carried 
on  in  the  homes  of  the  artisans. 

The  undue  prevalence  of  plumbism  among  the  diamond  cutters  in  the 
Netherlands  induced  the  Dutch  Government  to  ofifer  a  prize  for  a  suitable 
substitute  for  lead  in  the  alloy,  which  has  not  yet  been  awarded. 

It  is  reported  by  Oliver  that  some  of  the  gem  polishers  in  Oldenburg  use 
an  alloy  of  tin,  copper  and  bronze,  and  Rambousek,  in  referring  to  the  industry 
in  Bohemia,  states  that  the  authorities  have  required  substitution  of  silicon 
carbide  for  lead  discs. 

The  work,  apart  from  danger  of  lead  poisoning,  involves  eye  strain,  and 
is  often  carried  on  under  unfavorable  environments  as  regards  light,  ventila- 
tion and  heating.  A  combination  of  factors,  such  as  bad  air,  sedentary 
habits,  inhalation  of  dust,  and  ingestion  of  lead  are  doubtless  responsible  for 
much  of  the  ill  health.  According  to  Tracy,  52  per  cent,  of  the  cutters  or 
polishers  employed  in  Coster's  factory  at  Amsterdam  were  thin  and  pale,  40 
per  cent,  were  asthmatic,  and  33.75  per  cent,  suffered  from  headache,  etc. 
Cases  of  lead  poisoning  are  doubtless  as  common  among  the  cutters  as  among 
the  setters. 

Preventive  Measures. — Since  it  has  been  shown  that  an  efficient  sub- 
stitute for  lead  exists,  the  use  of  lead  discs  should  be  prohibited.  All  polish- 
ing processes  should  be  carried  on  by  the  wet  process  and  guarded  by  hoods 
and  efficient  exhaust  ventilation.  Frequent  ablutions  and  all  the  safeguards 
against  lead  poisoning  should  be  invoked.  Good  general  ventilation,  ad- 
justable work  benches,  and  improved  working  conditions  as  regards  light, 
air-space,  and  heating,  are  recommended. 

The  Glass  Industry. — This  industry  includes  the  manufacture  of  window 
glass,  plate  glass,  and  all  varieties  of  cast  and  rolled  glass,  pressed  and  blown 
glass,  such  as  jelly  cups,  tableware,  tumblers,  goblets,  lamp  chimneys,  lan- 
tern globes,  electric  light  bulbs  and  globes,  opal  ware,  cut  glass,  bottles,  jars, 
demijohns,  etc.  During  the  last  U.  S.  census  68,911  wage  earners,  inclusive 
of  4762  females  and  3561  children  under  16  years  of  age,  were  employed  in 
this  industry;  53.2  per  cent,  were  employed  in  establishments  where  the  pre- 
vailing hours  of  labor  were  54  hours  or  less  per  week;  20.2  per  cent,  worked 
between  54  and  60  hours  and  26.6  per  cent,  over  60  hours  per  week.' 

Glass  is  manufactured  by  the  combination  of  a  fusible  alkaline  silicate 
of  potash  or  soda  with  one  or  more  infusible  silicates  of  lime,  magnesia,  iron, 
chromium,  etc.     Crown  glass,  for  e.xample,  is  composed  of  silica  62.8,  lime 


638        ETIOLOGY   AND   PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

12.5,  potash  22  and  alumina  2.6.  Flint  glass  contains  silica  38.2;  lead  oxide 
48.5,  potash  II. 7  and  alumina  2.  Optical  lenses  and  imitation  precious  stones 
are  generally  made  of  the  best  quality  of  flint  glass.  Most  of  the  glasses  are 
Jeadless.  Arsenic  is  used  as  a  de-colorizing  agent,  but  cases  of  arsenical  poison- 
ing are  comparatively  rare,  inspite  of  the  fact  that  dust  in  glass  works  has 
been  found  to  contain  as  much  as  1.5  per  cent,  of  white  arsenic.  Chromium 
and  manganese  compounds  and  various  chemicals  are  used  for  coloring  or  de- 
colorizing purposes.  The  mixing  of  raw  materials  is  usually  a  very  dusty 
process  and  the  fusing  and  glass-blowing  process  involves  exposure  to  intense 
light  and  heat.  Glass-blowing  by  machinery  is  at  present  limited  to  the  manu- 
facture of  glass  bottles,  which  are  moulded  or  blown  by  machines  using  com- 
pressed air.  Plate  glass  is  cast,  and  most  of  the  table  glass  ware  is  moulded 
and  pressed  into  shape  by  machines.  It  is  hoped  that  the  machine  process 
will  come  into  use  before  long  in  the  manufacture  of  large  glass  carboys. 
The  work  of  blowing  large  pieces  of  glass  is  often  so  strenuous  that  the  pipe  is 
passed  in  succession  from  one  operator  to  another,  which  practice  has  been 
the  means  of  spreading  syphilis.  A  number  of  small  factory  epidemics  were 
reported  before  the  Internat.  Med.  Congress  in  Paris  in  1876.  Eysel,^^  in 
1896,  reported  12  instances  and  Brosius,  in  1904,  added  to  the  number  of 
wholesale  transmissions;  isolated  cases  are  not  infrequent.  Hayhurst  cites 
a  case  in  his  Ohio  Survery  on  page  261.  Cases  of  heat  prostration  are  not 
uncommon  and  exposure  to  intense  heat  and  light  is  responsible  for  an  undue 
prevalence  of  diseases  of  the  eye,  notably  chronic  inflammation  and  dryness 
of  the  conjunctivae,  and.most  important  of  all  is  the  large  number  of  cataracts 
observed  in  glass-blowers.  Meyhoffer'*^  found  this  condition  among  506  glass- 
blowers  in  59  men  of  whom  42  had  not  yet  attained  the  age  of  40.  Hirsch- 
berg  attributes  this  to  direct  heat  absorption,  others  suggest  that  the  loss 
of  bodily  fluids  on  acount  of  excessive  perspiration,  may  be  a  factor.  It  is 
probably  caused  by  the  combined  effect  of  both.  In  a  recent  discussion  of  the 
subject  in  London,  Mr.  Cridland  suggested  the  name  of  "ray  cataract" 
as  a  more  inclusive  term  and  the  President  suggested  the  name  of  "furnace 
workers  cataract"  because  the  affection  is  not  uncommon  among  puddlers 
(J.  A.  M.  A.,  April3,  1915,  page  1186;  see  also  page  331  of  this  volume).  The 
tradition  that  glass-blowers  are  especially  Hable  to  develop  emphysema  of 
the  lungs  has  been  rudely  shaken  by  Prettin  and  Liebkind,^^  who  found  only 
five  cases  among  230  glass-blowers  who  had  been  engaged  for  over  10  years 
in  this  work.  Similar  observations  have  been  made  in  German  Military 
bands,  and  we  quite  agree  with  Schmidt^^  that  the  elasticity  of  the  normal 
lung  tissue  may  withstand  the  additional  strain.  That  the  buccal  cavity  is 
taxed  to  an  enormous  extent  is  shown  by  the  great  dilatation  of  the  cheeks 
and  flabljy  muscular  atrophy,  which  in  older  glass-blowers  occasionally  re- 
sults in  hernia  of  the  cheeks  and  dilatation  of  Steno's  duct. 

As. a  result  of  exposure  to  excessive  heat  and  sudden  changes,  catarrhal 
affections  and  diseases  of  the  respiratory  organs,  which  are  often  aggravated 


MINING,   QUARRYING    AND    ALLIED    INDUSTRIES  639 

by  smoke  and  dust  in  badly  regulated  establishments,  lead  the  list.  Accord- 
ing to  Hoffman's  statistics  39.4  per  cent,  of  all  the  deaths  among  glass-blowers 
were  caused  by  respiratory  diseases,  inclusive  of  30.1  per  cent,  from  consump- 
tion. The  German  morbidity  rate  for  respiratory  diseases  was  32.7  per  cent. 
Congestive  headaches  from  exposure  to  heat,  and  diseases  of  the  digestive 
organs  from  excessive  use  of  cold  drinks  are  also  quite  common.  Injuries 
and  wounds,  painful  and  inflamed  callosities  in  the  palm  of  the  hands,  from 
handling  rough  glass,  and  eczema,  caused  by  glass  dust,  are  not  infrequent. 

The  workers  engaged  in  dry  grinding,  sanding,  filing,  drilling,  bevelUng 
and  glass  polishing,  especially  in  the  crystal  or  so-called  cut-glass  industry, 
are  exposed  to  the  inhalation  of  rouge  and  putty  powder.  OUver  has  found 
that  some  putty  powder  contained  as  high  as  70  per  cent,  of  lead  compounds. 
Forty-eight  cases  of  lead  poisoning  were  reported  in  Great  Britain  from  1900 
-9  from  the  use  of  putty  powder.  Attempts  to  secure  putty  powder  free  from 
lead  have  so  far  failed.  In  France  a  compound  of  metastannic  acid  has  been 
used  with  success  and  in  this  country  most  of  the  glass  polishing  and  etching 
is  done  by  means  of  hydrofluoric  acid  mixed  occasionally  with  other  acids 
such  as  acetic,  carbolic  acids,  etc.  This  process,  however,  is  not  free  from 
danger,  as  the  inhalation  of  acid  fumes  is  injurious,  and  contact  with  the  skin 
is  liable  to  cause  burns  in  the  second  degree,  and  slow  healing  ulcers,  with 
loss  of  finger  nails,  etc.  Sand  blasting  is  being  employed  to  some  extent  to 
replace  the  dangerous  process  of  etching  by  means  of  hydrofluoric  acid. 
Dr.  Hayhurst  in  his  Ohio  Survey  refers  to  another  substitute  for  etching,  in 
which  the  design  is  stamped  on  the  glass  with  a  paste  and  dusted  over  with 
zinc  oxide.  This  work  is  done  under  a  hood,  after  which  the  glass  is  heated 
and  the  finished  product  resembles  very  closely  etched  ware.  The  different 
art  glass  processes,  such  as  assembling  in  metal  frames,  lacquering,  varnish- 
ing, etc.,  involve  exposure  to  the  fumes  of  amyl  acetate,  wood  alcohol,  ben- 
zine and  turpentine,  and  even  lead  in  handling  and  soldering  metal  com- 
position frames. 

Workers  engaged  in  decorative  painting  and  spraying  of  glass  may  be 
exposed  to  lead  color  pigments,  and  persons  employed  in  the  silvering  of  glass 
pearls  are  liable  to  develop  argyria,  a  shiny  black  discoloration  of  the  skin, 
caused  by  the  absorption  and  excretion  of  silver  compounds. 

The  danger  of  glass  dust  inhalation  is  plainly  revealed  by  the  undue 
prevalence  of  respiratory  diseases.  Hoffman's  statistics  show  that  47.4  per 
cent,  of  the  glass  cutters  perish  from  diseases  of  the  respiratory  organs,  in- 
clusive of  34.5  per  cent,  from  tuberculosis.  The  presence  of  lead  will,  as  in 
printers,  naturally  act  as  an  additional  predisposing  factor.  The  average 
duration  of  Kfe  in  the  German  glass  poUshers  is  given  by  Anacker  as  32.6 
years.  Dust  production  is  not  so  great  in  the  manufacture  of  optical  lenses, 
but  constitutes  nevertheless  an  injurious  factor.  For  dangers  in  the 
manufacture  of  thermometers,  etc.,  see  workers  in  mercury,  page  524. 

Preventive  Measures. — All  raw  material  should  be  ground  and  mixed  in 


640        ETIOLOGY    AND    PROPHYLAXIS    OF    OCCUPATIONAL    DISEASES 

enclosed  machinery  provided  with  exhaust  ventilation.  Appert's  apparatus, 
which  is  operated  by  compressed  air,  should  replace  as  far  as  practicable  the 
glass-blower's  pipe.  Metallic  and  asbestos  screens  for  protection  from  intense 
heat  should  be  provided.  Dark  eye  glasses  as  a  protection  from  intense  heat 
and  light  should  be  worn.  All  pohshing  processes  should  be  safeguarded 
by  adequate  exhaust  ventilation.  Protection  of  the  hands  and  wrists  for 
men  who  handle  plate  glass  is  important.  Washing  and  bathing  facilities, 
special  lunch  rooms,  change  of  clothing,  periodical  medical  inspections, 
educational  methods,  and  all  the  precautions  against  lead  poisoning  are 
recommended. 

Mineral  Wool. — The  manufacture  of  mineral  wool  is  closely  connected 
with  blast-furnace  operations  since  it  is  obtained  by  subjecting  furnace  slag, 
while  molten,  to  a  strong  blast  such  as  steam  under  pressure.  This  causes  a 
mass  of  fine  interlaced  filaments,  resembling  wool  or  cotton,  which  are  col- 
lected in  wire  receptacles.  The  operation  is  naturally  attended  with  the 
evolution  of  dust  quite  as  irritant  in  its  effects  as  glass  dust.  The  material 
is  also  known  as  "mineral  cotton,"  "silicate  cotton,"  and  "slag  wool,"  and 
is  used  for  covering  boilers  and  steam  pipes,  and  as  a  filler  in  ceiling  spaces  to 
deaden  sound,  etc.  The  manufacture  and  use  of  this  material  involves 
exposure  to  a  dangerous  kind  of  dust. 

Workers  in  Rontgen  Tubes  and  Rontographers. — The  men  engaged  in 
the  manufacture  and  use  of  Rontgen  tubes  are  exposed,  unless  properly 
protected,  to  certain  injurious  effects  of  the  Rontgen  rays.  These  effects  are 
especially  liable  to  manifest  themselves  in  inflammatory  conditions  of  the 
skin  and  burns  varying  in  degree,  according  to  the  intensity  of  the  rays, 
duration  of  exposure,  and  delicacy  of  the  skin.  In  some  instances  burns  have 
resulted  in  extensive  destruction  of  the  skin  and  large  slow  healing  septic 
ulcers.  The  more  commonly  observed  effects  manifest  themselves  in  the 
form  of  a  chronic  inflammation  of  the  skin,  characterized  by  hypertrophy  of 
the  horny  layer  and  a  furrowed,  dry,  rough  and  parchment-like  appearance 
of  the  skin.  Fissures  and  painful  excoriations,  hard  warts,  deformities  of  the 
finger  nails,  felons  and  loss  of  hair  are  not  uncommon.  While  most  of  the 
damage  usually  falls  upon  the  hands  of  the  operator,  the  face  and  other 
portions  of  the  body  may  be  involved  and  even  cases  of  cataract  have  been 
observed  in  connection  with  burns  of  the  face.  Loss  of  hair  and  atrophy  of 
the  skin  not  infrequently  gives  rise  to  a  red  shiny  disfiguration  of  the  skin. 
In  some  cases,  telangiectases  with  stellate  dark  spots  have  been  observed  on 
the  back  of  the  hands.  Cases  of  cancer,  engrafted  upon  chronic  ulceration 
from  X-ray  burns,  have  been  recordexl.  Atrophy  of  the  testicles  and  sterility 
as  a  result  of  repeated  exposure  to  Rontgen  rays  have  likewise  been  reported. 
Von  Jagic^^  found  a  marked  lymphocytosis  (35-52  per  cent,  in  10  X-ray 
workers  and  also  reports  three  cases  of  lymphatic  leukemia  in  rontographers 
and  one  in  a  chemist  who  prepared  radium.  Animal  experimentation  led  him 
to  the  conclusion  that  both  the  X-ray  and  radium  act  upon  the  bone-marrow 


MINING,   QUARRYING   AND    ALLIED    INDUSTRIES  64 1 

cells  and  stimulate  the  activity  of  lymphatic  tissue.  All  of  these  effects  are 
less  commonly  observed  now  and  will  continue  to  decrease  by  the  employment 
of  precautionary  measures  (see  also  page  391  and  525). 

Preventive  Measures. — Formerly  the  men  engaged  in  the  manufacture  of 
the  Rontgen  tubes  made  the  test  upon  their  own  hands  and  thus  incurred 
special  risks.  This  danger  has  been  obviated  by  mounting  the  skeleton  of 
the  hand  in  a  paper  mache  or  wax  model  to  which  a  leaden  handle  is  attached. 
In  modern  establishments  it  is  now  the  practice  to  shield  the  body  by  means 
of  suitable  sheet-lead  screens,  and  for  the  protection  of  the  eyes  lead-glass 
observation  windows  and  goggles  are  employed. 

The  universal  use  of  these  screens  together  with  making  the  exposure  as 
brief  as  practicable  will  not  only  protect  the  maker,  but  also  the  rontographer 
and  thus  eliminate  the  ill  eflfects  of  the  Rontgen  rays,  which  play  a  very 
important  role  in  modern  methods  of  precision  in  diagnosis  and  also  for 
therapeutic  purposes. 

Radium. — The  effects  of  exposure  to  radium  apparently  do  not  differ 
essentially  from  those  of  the  X-ray.  So  far,  probably  because  of  its  limited 
employment  and  briefer  periods  of  exposure,  no  very  serious  injuries  have 
been  reported.  While  acute  forms  of  dermatitis,  with  redness,  swelhng, 
itching  and  burning  sensations  and  even  deep-seated  ulcerations  have  been 
reported,  the  skin  lesions  are  generally  of  a  chronic  type  and  characterized 
by  hyperkeratoses  of  the  lateral  surfaces  of  the  fingers. 

Preventive  Measures. — Sheet-lead  screens,  lead-glass  observation  windows 
and  goggles,  and  careful  time  limits  of  exposure  have  so  far  afforded  the  best 
protection. 

Robinson  and  Wilson*^  found  no  cases  of  tuberculosis  among  the  grinders 
of  lenses  and  17  workers  in  an  art  glass  factory  of  Cincinnati.  No  cases  of 
tuberculosis  were  found  among  31  persons  engaged  in  the  manufacture  of 
glass  signs,  in  which  the  lettering  was  etched  in  with  hydrofluoric  acid  and 
sand  blasting  was  also  resorted  to.  Both  processes  were  safeguarded  how- 
ever by  an  exhaust  system. 

Among  245  workers  examined  in  the  stone  and  clay  industry,  eight  persons 
or  3.26  per  cent,  were  found  to  be  tuberculous;  five  of  these  were  among 
marble  workers,  two  in  a  pottery  and  one  in  a  tile  works.  This  is  a  much 
higher  rate  than  that  in  most  of  the  other  industries  investigated. 

REFERENCES 

1  Lindemann.— Trans.  15th  Int.  Congress  Hygiene,  Vol.  Ill,  Part  II,  Washington,  1913. 

2  Bulletin  69,  Bureau  of  Mines,  1913. 

3  Fay,  Albert  H.— Technical  Paper  No.  94,  Bureau  of  Mines,  Washington,  D.  C,  1914. 

*  Technical  Paper  11,  U.  S.  Bureau  of  Mines,  1912,  page  13. 

*  The  Coal  and  Metal  Miners  Pocket  Book,  Scranton,  1904. 

«  Ebright.— Jour.  Am.  Med.  Assoc,  Vol.  LXII,  Jan.  17,  1914,  page  201. 

^Oliver,  Sir  Thomas.— Dust  and  Fumes,  General  Address  Delivered  before  isth  Inter. 

Congress  on  Hygiene  and  Demography,  Wash.,  D.  C,  1913. 

41 


642        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

*  Diseases  and  Accidents  of   Miners  and  Tunnel  Workers   in  U.  S.,  15th  Int.  Cong,  on 

Hyg.,  Vol.  Ill,  Part  II,  Washington,  D.  C,  1913. 
^  Diseases  and  Accidents  of  Miners  and  Tunnel  Workers  in  U.  S.,  15th  Int.  Cong,  on 

Hygiene,  etc..  Vol.  Ill,  Part  II,  1913,  page  691. 
»o  Johnson,  G.  W.— Journ.,  Canada  Med.  Asso.,  Feb.,  191 2. 

11  Nieszytka.— Viertaljahrscht  f.  Gericht,  Medizin,  etc.,  1912,  Vol.  XLIII,  Suppl.  Heft  i 

and  2,  page  143. 

12  Nieszytka. — Loc.  cit. 

1'  Koelsch. — Krankheit  u.  Soziale  Lage,  ist  Liefg.,  Munchen,  191 2. 

"  Selkirk. — Jour.  Am.  Med.  Assoc,  December  12,  1908. 

'*  Butler. — Ophthalmoscope,  191 2,  page  686. 

1*  Day,  W.  C. — Report  on  the  Stone  Industry,  U.  S.  Geological  Survey,  1908. 

"^  Hoffman,  F.  L. — Bulletin,  U.  S.  Bureau  of  Labor,  No.  79,  1908,  page  685. 

1*  Report  of  the  State  Board  of  Health  of  Mass.  upon  the  Sanitary  Condition  of  Factories, 
Workshops,  etc.,  1907,  page  79. 

"  Kompendium  der  Gewerbekrankheiten,  Berlin,  1904,  page  26. 

2"  Report  of  the  State  Board  of  Health  of  Mass.  upon  the  Sanitary  Condition  of  Factories, 
Workshops,  etc.,  1907,  page  79. 

"  Kober,  Geo.  M. — Bulletin  No.  3,  Vol.  XIII,  Vermont  State  Board  of  Health,  March,  1913. 

"  Hoffman,  F.  L. — Exhibit  of  the  Prudential  Insur.  Comp.  of  America,  191 2. 

2^  Oliver. — Diseases  of  Occupation,  London,  1908. 

^*  Gottschalk. — Weyl's  Handbuch  d.  Arbeiterkrankheiten,  1908,  page  312. 

2*  Oliver. — Industrial  Lead  Poisoning  in  Europe.  Bull.  Bureau  of  Labor,  No.  95,  Washing- 
ton, July,  191 1. 

2*  Kaup,  cited  by  Rambousek. — Industrial  Poisoning,  London,  1913. 

"  Holitscher. — Weyl's  Handbuch  d.  Arbeiterkrankh.,  1908,  page  319. 

-*  Rambousek. — Industrial  Poisoning,  London,  1913,  page  137. 

^^  Oliver. — Industrial  Lead  Poisoning  in  Europe.  Bull.  Bureau  of  Labor,  No.  95,  July,  191 1, 
Washington,  D.  C. 

'"Hamilton,  Alice. — Trans.  15th  Inter.  Congress  on  Hyg.,  Washington,  1913,  Vol.  Ill, 
Part  II,  page  817. 

'^  Oliver. — Industrial  Lead  Poisoning  in  Europe.  Bull.  Bureau  of  Labor,  No.  95,  July,  191 1, 
Washington,  D.  C. 

»2  Miinch.  Med.  Wochschft,  LXI,  756. 

"  Koelsch. — Krankheit  und  Soziale  Lage,  ist  Liefg.,  Munchen,  1912. 

^*  Wittgen. — Concordia,  1912,  page  37. 

'^  Ascher. — Weyl's  Handbuch  d.  Arbeiterkrank.,  1908,  page  330. 

"^  Hoffman,  F.  L. — Exhibits  of  the  Prudential  Insurance  Co.  of  America.,  Internat.  Con- 
gress on  Hygiene,  etc.,  September,  191 2. 

"  Oliver. — Diseases  of  Occupation,  London,  1908. 

'*  Report  of  the  Massachusetts  State  Board  of  Health  upon  the  Sanitary  Condition  of 
Factories,  Workshops,  etc.,  1907,  page  77. 

5'  Hoffman. — Bull.  Bureau  of  Labor,  No.  79,  page  700,  Washington,  D.  C,  1908. 

"  Oliver. — Bull.  Bureau  of  Labor,  No.  95,  Washington,  D.  C,  191 1. 

"  Eysel.— Inaug.  Dissertat.,  Gottingen,  1896. 

^•-Meyhoffer.— Zehender  Klin.  Monatsbt.  f.  Augenkrankh.  24,  Vol.  XLIX. 

^'Prettin  and  Liebkind. — Miinch.  Med.  Wochenschft.,  1904. 

^■»  Schmidt. — Weyl's  Handbuch  d.  Arbeiterkrank.,  1908,  page  350. 

*^  Von  Jagic— Berl.  Klin.  Woch.,  191 1,  XLVIII,  page  1220. 

■■«  Robinson,  D.  E.,  and  Wilson,  J.  G.— U.  S.  Public  Health  Bulletin  No.  73,  March,  1916. 


CHAPTER  VII 
THE  BUTTON,  HORN,  CELLULOID,  AND  ALLIED   INDUSTRIES 

BY  GEORGE  M.  KOBER,  M.  D.,  Washington.  D.  C. 

Button  Manufacture.    Vegetable  Ivory.     Pearl  Buttons.    Horn  Industry.     Manufacture 
of  Celluloid  Goods.     Preventive  Measures. 

Button  Manufacture. — Buttons  are  made  of  all  kinds  of  material,  such  as 
vegetable  ivory,  metal,  celluloid,  compositions  of  casein,  potatoes  and  mix- 
tures of  fossils  and  vegetable  gums  combined  -with  pulverized  carbonate  of 
lime,  feldspar,  etc.  In  1905  according  to  the  U.  S.  census  of  manufacture 
10,567  persons  were  employed  in  this  industry;  of  these  5085  were  engaged 
in  making  fresh  water  pearl  buttons  and  looi  in  the  manufacture  of  vegetable 
ivory  buttons. 

For  lack  of  space,  reference  can  be  made  only  to  these  two  classes  and 
to  the  manufacture  of  horn  buttons  as  likely  to  aflfect  the  health  of  the  wage 
earners. 

Vegetable  Ivory. — The  seed  of  the  fruit  of  the  South  American  ivory 
palm  (phytelephas  marcrocarpa)  commonly  known  as  the  "ivory  nut"  is 
about  the  size  of  a  hen's  egg,  and  resembles  in  texture  and  color  genuine 
ivory.  In  sawing  the  material  into  suitable  sizes  and  shapes,  the  workmen 
are  exposed  to  large  amounts  of  coarse  sawdust,  which  is  difficult  to  remove 
by  suction.  The  Report  of  the  Mass.  State  Board  of  Health  Inspectors  for 
1908  (page  85)  states  that  one  plant  had  spent  a  large  amount  of  money  in 
trying  to  adapt  a  blower  system  to  its  sawing  machines  without  success. 
A  much  finer  dust  is  produced  by  the  machines  which  cut  out  the  buttons 
and  drill  the  holes,  and  during  the  polishing  process,  all  of  which  can  be 
adequately  removed  by  suitable  suction  devices.  The  inhalation  of  this 
dust,  like  that  of  horn  and  genuine  ivory  dust,  with  their  sharp  and  angular 
fragments,  predispose  to  diseases  of  the  respiratory  organs,  while  the  dust 
from  bone  is  classed  by  Professor  Roth^  among  the  less  offensive  varieties 
of  dust. 

Since  vegetable  ivory  is  especially  adapted  to  the  application  of  colors, 
there  is  an  element  of  danger  if  toxic  pigments  or  dyestuffs  are  used. 

Pearl  Buttons. — In  the  manufacture  of  pearl  buttons,  studs  and  orna- 
ments, the  shells  of  mullosks  are  used;  after  cooking,  the  shells  are  freed  from 
the  fleshy  parts,  sorted  into  three  sizes  and  soaked  for  several  days  in  water 
to  render  them  less  brittle.  While  still  wet  the  shells  are  sawed  into  suitable 
blanks;  this  as  well  as  the  subsequent  processes  such  as  cutting  out  the  discs, 

643 


644        ETIOLOGY   AND   PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

boring,  planing,  facing,  grinding,  polishing  and  doming  are  all  attended  with 
the  production  of  dust.  The  wage  earners  include  a  large  number  of  females 
and  minors.  The  inhalation  of  this  dust  produces  dyspeptic  conditions  and 
catarrhal  affections  of  the  respiratory  passages,  such  as  chronic  bronchitis 
which  may  eventuate  either  in  fibroid  phthisis  or  in  pulmonary  tuberculosis. 

Of  390  deaths  among  the  button  workers  in  Vienna  between  1895  and 
1905,  no  less  than  272  or  69.7  per  cent,  perished  from  consumption,  and 
Teleky2  j^  an  examination  of  150  pearl  button  workers  in  1907  found  only 
93  with  normal  lungs. 

Professor  Roth  states  that  mother-of-pearl  dust  is  largely  composed  of 
carbonate  of  lime  and,  as  such,  less  offensive.  Reference  should  be  made  to  a 
peculiar  inflammation  of  the  bones  (osteomyelitis)  which  most  frequently 
affects  the  bones  of  the  forearm  and  hand  and  occasionally  also  the  shoulder 
blades,  jaw-bone  and  the  bones  of  the  lower  extremities,  especially  of  youthful 
workers.  This  disease,  first  described  in  1869  by  Englisch  as  attacking 
"pearl  turners,"  was  subsequently  studied  by  Gusenbauer,  Weiss,  Fischer  and 
others,  and  in  all  about  31  cases  have  been  recorded.  The  etiology  still  re- 
mains obscure,  but  is  generally  attributed  to  the  absorption  of  some  of  the 
constituents  of  the  shell  dust,  causing  embolic  processes  in  the  bone.  What- 
ever the  factors  such  as  the  grinding  process,  water  or  air  may  be,  which 
predispose  to  this  affection  in  Germany  and  France,  the  only  two  countries  in 
which  cases  have  been  reported,  the  disease  does  not  exist  according  to  Oliver* 
among  the  pearl  workers  in  the  shops  of  Sheffield  where  the  grinding  is  done 
by  the  wet  process. 

Neisser*  refers  to  instances  in  a  pearl  factory  in  France  of  severe  nose 
bleed,  pricking  in  the  eyes,  bronchial  and  even  gastric  irritation,  caused  by 
the  dust  of  shells  from  certain  mollusks,  the  symptoms  differing  so  radically 
from  those  produced  by  the  genuine  mother-of-pearl  dust  that  the  employees 
promptly  stop  work  in  these  shells. 

The  mortality  statistics  of  button  makers  in  the  United  States  from  1897 
to  1906  collected  by  Hoffman^  are  based  upon  127  deaths  from  all  causes 
reported  in  only  one  of  the  Industrial  Insurance  Companies;  of  these  48  or 
37.8  per  cent,  died  from  consumption  as  compared  with  14.8  per  cent,  for 
males  in  the  registration  area;  there  were  also  14  deaths  or  11  per  cent, 
from  other  diseases  of  the  lungs. 

Preventive  Measures. — The  mortality  statistics  from  diseases  of  the 
respiratory  system  sufficiently  indicate  that  the  occupation  as  at  present 
carried  on  is  injurious  to  life  and  health,  and  that  every  effort  should  be 
made  to  reduce  dust  production  to  a  minimum  by  wet  processes  and  to 
provide  for  its  removal  by  effective  exhaust  ventilation.  This  at  present 
appears  to  be  not  wholly  possible,  since,  "notwithstanding  the  best  pro- 
tective devices  found  in  the  way  of  hoods  and  exhausts,  there  was  some 
escape  of  dust,  as  evidenced  by  the  fact  that  the  fine  white  pearl  dust 
covered  the  belts,  machines,  walls,  ceilings,  clothing  and  often  the  faces  of 


THE  BUTTON,   HORN,    CELLULOm,    AND    ALLIED    INDUSTRIES        645 

the  workers  in  those  establishments  which  provided  the  most  improved 
methods  of  protection."^ 

The  State  of  Massachusetts  since  19 10  excludes  boys  and  girls  under 
18  years  of  age  from  all  processes  involving  the  evolution  of  dust.  In  the 
prevention  of  the  pulmonary  affections  social  and  industrial  betterment  will 
play  an  important  part,  and  as  a  preventive  measure  against  inflammatory 
affections  of  the  jaw  Dr.  Ritter,  a  Berlin  dentist,  recommends  care  of  the 
teeth  and  astringent  mouth-washes. 

Horn  Industry. — Horn  is  extensively  used  in  the  manufacture  of  mouth- 
pieces for  pipestems,  handles  for  carving  sets,  buttons,  combs,  hairpins,  orna- 
ments, frames  for  eye-glasses,  etc. 

In  the  manufacture  of  horn  buttons,  the  hoofs  of  cattle  are  generally 
used;  after  boiling  to  soften  them  they  are  cut  by  machines  into  pieces,  while 
still  other  machines  shape  them  into  buttons;  they  are  then  stamped  into 
the  desired  pattern  by  means  of  hydraulic  presses;  all  of  these  manipulations 
are  less  dusty  than  the  subsequent  drilling  of  the  holes  and  the  polishing 
process. 

Combs,  Hairpins,  Etc. — In  the  manufacture  of  combs,  hairpins  and 
similar  ornaments,  various  materials  such  as  horn,  bone,  tortoise  shells, 
celluloid,  ivory,  composition  material  and  different  metals  are  used.  Refer- 
ence can  be  made  here  only  to  those  materials  involving  the  inhalation  of 
dust.  Apart  from  the  liability  to  mechanical  injuries  during  the  process 
of  cutting  the  horn  into  laminae  by  means  of  circular  saws,  all  of  the  manipu- 
lations such  as  sawing  and  turning  of  the  horn,  and  especially  the  process 
of  rounding  and  pointing  of  hairpins  and  subsequent  rubbing  and  polishing, 
are  attended  with  considerable  production  of  dust.  There  is  also  an  element 
of  danger  during  the  coloring  of  the  goods  with  a  mixture  containing  aniline 
dyes,  red  lead,  lime  and  saleratus.  Dr.  Power^  refers  to  the  liability  of  horn 
workers  to  anthrax  infection,  but  cites  no  specific  instances.  According 
to  Hirt  the  inhalation  of  dust  of  animal  origin  is  more  conducive  to  the  de- 
velopment of  consumption  than  dust  of  vegetable  origin,  the  consumption 
rates  being  respectively  20.8  and  13.3,  and  for  workers  in  non-dusty  trades 
only  II. I  per  1000. 

Manufacture  of  Celluloid  Goods. — The  use  of  celluloid  in  the  manufacture 
of  combs,  pins,  frames  for  eye-glasses,  knife  and  umbrella  handles,  billiard 
balls,  buttons,  collars,  cuffs,  etc.,  is  of  comparatively  recent  date.  Celluloid, 
also  known  as  fiberloid,  invented  by  Hyatt  an  American  in  1869,  is  a  mixture 
of  pyroxiline,  camphor  and  alcohol.  Pyroxiline  is  primarily  obtained  by 
treating  vegetable  fiber,  usually  tissue  paper,  with  nitric  acid  and  sulphuric 
acid  in  stone  jars.  This  process  gives  rise  to  the  evolution  of  nitrous  fumes 
and  sulphureted  hydrogen,  to  which  the  workmen  are  exposed,  even  though 
the  process  is  well  guarded  by  hoods  and  exhaust  ventilation.  After  macera- 
tion in  the  acid  solution,  the  material  is  freed  of  most  of  the  acid  and  washed; 
it  is  then  dried  and  mixed  with  wood  alcohol  and  camphor  and  the  final 


646        ETIOLOGY   AND   PROPHYLAXIS    OF   OCCUPATIONAL  DISEASES 

mixture  is  kneaded  and  moulded  or  rolled  into  sheets  of  suitable  sizes  for 
manufacture  of  celluloid  combs  and  other  goods. 

The  manufacture  of  celluloid  combs,  especially  the  process  of  "shaping" 
and  "pointing"  the  teeth,  and  the  rubbing  and  polishing,  involves  more  or 
less  dust  production,  which  can  be  removed  to  a  great  extent  by  eflSicient 
exhaust  ventilation. 

In  recent  years  in  order  to  obviate  much  of  the  hand  poUshing  processes 
a  dip  containing  glacial  acetic  acid  and  other  unknown  constituents  has  been 
employed,  the  fumes  of  which  are,  however,  very  irritating  to  the  mucous 
membranes  of  the  eyes  and  to  a  less  extent  to  the  nose  and  throat. 

Fortunately,  good  blowers  are  required  by  fire  insurance  companies  on 
account  of  the  extremely  inflammable  character  of  the  celluloid  dust.  There 
is  some  danger  of  injury  to  the  eyes,  from  flying  chips  of  celluloid  caused  by 
the  circular  saw  employed  in  "shaping"  the  bottom  of  the  teeth  and  also  in 
the  "pointing"  of  the  teeth  by  sand  wheels  or  steel  burrs,  unless  glass  fronts 
and  efiScient  blowers  are  used. 

Preventive  Measures. — The  chief  elements  of  danger  in  the  horn  and 
celluloid  industry  are  exposure  to  dust,  acid  and  toxic  fumes,  especially  when 
cyanogen  compounds  are  used,  wood  alcohol,  toxic  color  pigments,  fire  and 
explosions.  The  obligatory  installation  of  exhaust  ventilation  is  not  only  a 
fire  but  also  a  health  protection;  in  addition  some  underwriters  require  a 
thermostat  system  of  automatic  sprinklers.  A  recent  inspection  of  one  of 
the  Brooklyn  establishments  satisfied  the  writer  that  the  horn  and  celluloid 
industry  can  be  carried  on  under  favorable  hygienic  conditions. 

REFERENCES 

1  Roth,  E. — Gewerbehygiene,  1907,  page  119. 

2  Teleky,  L. — Weyl's  Handbuch  fiir  Arbeiterkrankheiten,  1908,  page  326. 
^  Oliver's  Dangerous  Trades,  page  276. 

*  Neisser. — Internat.  Ubersicht  uber  Gewerbehygiene,  1907,  page  132. 

^  Hoffman,  F.  L. — Bull.  Bureau  of  Labor,  No.  82,  May,  1909,  page  515. 

«  Report  of  the  Massachusetts  State  Board  of  Health  upon  the  Work  of  State  Inspectors, 

1909,  page  29. 
'  Oliver's  Dangerous  Trades,  1902,  page  244. 


CHAPTER  VIII 
THE  TEXTILE  AND  ALLIED  INDUSTRIES 

BY  GEORGE  M.  KOBER.  M.  D.,  Washington,  D.  C,  AND  WILLIAM  G.  HANSON.  M.  D., 

Belmont,  Mass. 

The  Cotton  Industry.  Manufacture  of  Woolen  and  Worsted  Goods.  Manufacture  of 
Carpets  and  Rugs.  JNIanuf acture  of  Flax  and  Linen.  Manufacture  of  Lace.  Manu- 
facture of  Cordage  and  Twine,  Jute  and  Hemp  Goods.  Dye  Works.  Preventive 
Measures. 

The  Cotton  Industry.* — The  work  of  cotton-mill  employees  involves  more 
or  less  constant  confinement  in  a  dusty  atmosphere  even  in  the  best  regu- 
lated mills.  The  presence  of  dust  in  the  air  of  cotton  workrooms,  however, 
does  not  appear  to  be  a  prominent  feature  except  in  the  first  few  processes 
which  cotton  undergoes  after  being  taken  from  the  bales.  The  intrinsic 
danger  in  the  industry  in  this  respect  lies  chiefly  in  the  opening,  picking,  and 
carding  processes,  the  danger  varying  with  the  construction  of  the  mill, 
the  amount  of  dirt  and  other  impurities  in  the  stock,  the  means  of  removing 
the  dust,  and  some  other  factors.^  A  careful  consideration  of  other  factors 
than  cotton  dust  which  afifect  injuriously  the  health  of  the  workers  shows  that 
too  little  attention  has  been  given  to  the  evil  consequences  of  poor  light 
(especially  in  certain  departments),  excessive  heat,  nauseating  odors,  irri- 
tating gases,  the  products  of  gas  combustion,  the  lack  of  proper  means  of 
ventilation,  the  failure  to  regulate  properly  the  introduction  of  artificial 
moisture,  and  want  of  cleanliness. 

By  eliminating  the  avoidable  dangers  and  the  associated  unnecessary 
conditions  of  the  cotton  processes  the  exact  danger  caused  by  the  cotton  dust 
can  be  more  accurately  judged. 

Light.— Poor  hght  may  itself  reduce  the  physiological  resistance  to  dis- 
ease, or  it  may  be  a  concomitant  of  a  number  of  insanitary  influences  which 
affect  the  health  of  the  worker.  A  detailed  study  by  the  writer  of  several 
hundred  cotton  mill  buildings  in  Massachusetts  showed  conclusively  that 
too  little  thought  had  been  given,  in  mill  construction,  to  providing  for  light 
in  accordance  with  the  kind  of  work  to  be  done  in  a  given  room.  Some  of  the 
finer  goods  mills  were  remarkably  well  constructed,  however,  and  a  few  very 
old  buildings  where  coarse  and  colored  goods  were  manufactured  were 
operated  under  commendable  conditions.  Many  buildings  had  rooms  of  old 
construction,  with  low  ceilings,  small  windows  and  small  panes  of  glass. 
Some  of  these  rooms  were  narrow  and  admitted  fair  light  from  the  sides; 
but  some  were  wide,  and  some  were  basement  rooms  which  lacked  both  an 
ample  supply  and  an  even  distribution  of  light. 

*  By  Wm.  C.  Hanson,  Belmont,  Mass. 

647 


648        ETIOLOGY    AND   PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

Aside  from  the  question  of  mill  construction,  two  important  factors 
may  contribute  to  poor  light  viz.:  (i)  neglect  to  keep  the  ceiling  and  walls 
clean  and  white;  and  (2)  infrequent  washing  of  windows,  allowing  them  to 
go  unwashed  in  some  instances  for  several  years.  It  is  often  the  case  that 
prismatic  glass  of  different  kinds  and  sizes  is  introduced  into  poorly  lighted 
rooms;  but  unless  this  glass  is  kept  reasonably  clean,  it  is  of  little  value.  In 
poorly  constructed  and  neglected  rooms,  with  or  without  prismatic  glass, 
artificial  light  is  not  uncommonly  used  even  on  bright,  sunny  days  in  the 
late  morning  or  early  afternoon  hours;  and  in  such  rooms  incandescent  bulbs 
or  gas  jets  are  Ukely  to  be  found.  Even  if  artificial  light  is  not  used  until 
the  late  afternoon  hours,  there  is  then  much  variation  as  to  the  time  and 
method  of  lighting  and  the  kind  of  hght  in  use.  In  some  instances  the  light 
should  be  turned  on  half  an  hour,  or  longer,  before  the  engineer  sees  fit  to 
do  so;  yet  the  employees  during  this  time  are  supposed  to  continue  their 
work  with  the  same  degree  of  accuracy  and  rapidity  as  with  good  light. 

It  is  a  well-established  fact  that  either  the  overuse  of  the  eyes,  or  the 
use  of  eyes  under  bad  conditions,  may  give  rise  to  eye  fatigue  or  to  eye  strain; 
and  many  eye  specialists  believe  that  at  least  80  to  90  per  cent,  of  headaches 
are  dependent  upon  eye  strain. 

With  these  facts  in  mind,  it  is  impossible  to  ignore  the  probability  that 
many  individuals  working  by  gaslight,  or  even  electric  light,  in  dirty,  un- 
painted,  overheated  rooms,  with  impure  air  and  excessive  moisture,  for 
10  hours  a  day  or  merely  for  the  last  2  hours  during  the  day,  use  up  a  great 
deal  of  nervous  energy,  and  suffer  from  eye  fatigue,  or  eye  strain,  and  its 
consequences. 

In  the  weaving  and  spinning  departments  there  are  two  distinct  causes 
of  possible  injury  to  the  employees,  viz.,  (i)  insufl&cient  Hght  and  (2)  dust. 

Some  employees  may  be  exposed  to  both  sources  of  injury,  although 
it  is  not  usual  to  find  much  dust  in  a  weave  room.  The  department  where 
reasonably  good  light  is  important,  in  which  most  commonly  there  is  con- 
siderable dust,  is  that  of  ring  spinning.  Here,  on  account  of  the  character 
of  the  machinery  and  the  way  in  which  it  is  placed,  there  are  very  com- 
monly dark  alleys,  so  that  the  work  of  "finding  the  ends"  becomes  somewhat 
trying  to  the  eyes,  particularly  in  rooms  that  are  poorly  lighted. 

In  both  weaving  and  spinning  departments  there  are  a  number  of  other 
insanitary  influences  which  may  affect  the  health  of  the  workers,  the  effects 
of  any  one  of  which  are  not  susceptible  of  correct  measurement.  The  spin- 
ning rooms  are  often  excessively  hot;  the  temperature  in  the  winter  months 
is  commonly  above  9o°F.,  and  occasionally  above  ioo°F.  The  heat  gener- 
ated by  the  friction  of  the  machinery  in  a  ring-spinning  room  is  at  least 
sufficient  to  keep  the  room  at  a  good  spinning  temperature  in  the  winter 
months,  provided  the  room  is  at  a  proper  temperature  on  starting  in  the 
morning. 

Although  in  the  majority  of  the  ring-spinning  rooms  some  means  of 


THE    TEXTILE    AND    ALLIED    INDUSTRIES  649 

introducing  artificial  moisture  is  adopted,  the  methods  of  introducing  the 
moisture  vary  considerably,  while  in  some  rooms  no  artificial  moisture  is 
introduced.  In  a  considerable  number  of  spinning  and  a  large  number  of 
weave  rooms  the  means  of  introducing  moisture  is  by  the  old  steam  vapor 
pot,  which  many  agents  say  is  a  detriment  to  a  mill,  both  because  it  permits 
excessive  steam  and  heat,  and  because  the  regulation  of  humidity  is  prac- 
tically impossible.  In  addition,  therefore,  to  poor  light  and  some  dust  in 
many  of  the  weave  rooms  and  to  considerable  dust  and  poor  light  in  many 
of  the  spinning  rooms,  there  is  commonly  an  excess  of  moisture  with  un- 
necessary heat  in  weave  rooms,  and  excessive  heat  with  frequently  undue 
moisture  in  spinning  rooms.  Some  spinning  rooms  have  no  means  of  artificial 
moisture;  the  air  in  these  rooms  is,  as  a  rule,  very  dry. 

A  weave  room  with  poor  light,  unnecessarily  high  temperature,  with  some 
dust  and  an  excess  of  moisture,  is  not,  from  a  sanitary  point  of  view,  a  de- 
sirable room  to  work  in;  neither  is  a  spinning  room  with  considerable  dust 
flying  about,  together  with  excessive  heat  and  either  undue  moisture  or  no 
artificial  moisture  whatever.  Add  to  these  unhygienic  influences  two  promi- 
nent factors  which  enter  into  health  conditions  of  both  weave  and  spinning 
rooms,  viz.:  (i)  want  of  cleanliness  and  (2)  lack  of  provision  for  a  plentiful 
supply  of  fresh  air,  and  an  exceedingly  undesirable  class  of  rooms  is  repre- 
sented which  is  conspicuously  common  everywhere  among  weaving  and 
spinning  mills.  In  short,  the  conditions  commonly  met  with  in  weave  and 
spinning  rooms  are:  i.  Poor  light.  2.  Presence  of  carbon  dioxide  and 
carbon  monoxide  in  the  air.  3.  Non-regulation  or  unscientific  and  un- 
satisfactory regulation  of  artificial  moisture:  (a)  excess  of  moisture,  undue 
heat;  or  (b)  no  artificial  moisture,  excessive  heat.  4.  Dust  from  the  cotton 
and  from  "sizing,"  etc.  5.  Want  of  cleanliness.  6.  Want  of  provision 
for  a  plentiful  supply  of  fresh  air. 

The  presence  of  dust  in  the  air  of  workrooms  is  a  prominent  feature  in 
its  influence  on  health.  Aside  from  dirt  and  other  impurities  which  may  be 
in  the  stock,  the  vegetable  dusts  are  inimical  to  health.  Those  operatives 
in  cotton  mills  who  are  peculiarly  sensitive  to  unhygienic  influences  may 
become  seriously  affected  through  the  constant  irritation  of  cotton  dust  in 
the  upper  air  passages,  giving  rise  first  to  dryness  of  the  throat  and  later  to 
cough  and  expectoration.  There  are  many  departments  in  which  processes 
are  conducted  which  expose  the  employees  to  dust,  but  the  weaving,  spin- 
ning, carding  and  waste  rooms  illustrate  the  important  unhygienic  condi- 
tions commonly  associated  with  this  disturbing  element.  In  estimating  the 
effects  of  dust  upon  health,  the  following  considerations,  among  others,  are 
to  be  borne  in  mind: 

1.  Grade  of  stock  used,  e.g.,  quality  of  cotton. 

2.  Quantity  of  dust  in  a  given  room. 

3.  Whether  the  dust  is  constant. 


650        ETIOLOGY   AND   PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

4.  Type  of  construction  of  the  room. 

5.  System  of  management. 

6.  Number  and  kinds  of  other  unhygienic  influences  present. 

7.  Means  of  ventilation. 

8.  Health  and  susceptibility  of  the  individual. 

In  some  weave  rooms  the  air  is  so  filled  with  minute  bits  of  dust  as  to 
present  a  hazy  or  "smoky"  appearance  throughout  the  room,  and  parts 
of  the  room  are  covered  with  the  small  particles  which  have  settled  thereon; 
while  other  weave  rooms  are  practically  free  from  such  dust,  there  being 
merely  a  slight  amount  of  lint  or  dust  of  microscopic  fineness. 

Dust  in  ring-spinning  rooms  is  more  constant  and  is  greater  in  amount 
than  in  weave  rooms.  In  a  fine-goods  mill,  in  which  a  high  quality  of 
cotton  is  used  in  a  properly  constructed  and  well-regulated  room,  the  amount 
of  dust  present  is  comparatively  unimportant,  from  the  point  of  view  of 
health.  On  the  other  hand,  in  a  coarse-goods  mill,  where  waste  stock  is  used 
in  a  low-studded  and  generally  neglected  room,  the  amount,  constancy  and 
character  of  the  dust  is  such  as  to  suggest  the  probability  of  real  danger. 

While  in  both  weave  and  ring-spinning  rooms  there  are  many  unhygienic 
factors,  the  principal  features  of  the  card  room  are  (i)  the  amount  of  dust 
and  (2)  lack  of  proper  ventilation  and  effective  means  of  removing  the 
dust.  Cotton  dust  in  the  card  room  varies  greatly  both  in  quality  and 
quantity.  It  is  always  considerable,  owing  to  the  carding  process  of  freeing 
and  cleaning  the  material.  In  some  mills  it  is  enormous  in  amount,  with 
considerable  dirt  as  a  concomitant.  The  quantity  of  dust  is  commonly 
sufficient  to  cause  a  distinct  cloudiness  of  the  atmosphere,  which,  in  a  room 
lacking  proper  ventilation,  is  a  serious  menace  to  the  health  of  the  operatives. 

In  the  assorting  or  waste-room  "sweepings"  are  picked  over  and  the 
different  grades  separated.  Here  may  be  found  numerous  kinds  of  waste 
and  dirt,  including  that  which  comes  from  the  floors  of  the  card  and  spin- 
ning rooms,  and,  of  most  importance,  sputum  in  large  quantities,  which 
may  contain  the  exciting  causes  of  infective  diseases  of  the  respiratory  tract. 

A  comparison  of  the  important  constant  or  possible  unhygienic  influences 
in  the  ring-spinning  and  carding  departments,'  with  emphasis  upon  the 
dust  in  these  rooms,  is  as  follows:  Ring-spinning,  (i)  Considerable  dust 
(constant).  (2)  Infectious  dust  (dried  sputum).  (3)  Excessive  heat  (with 
artificial  moisture).  (4)  Excessive  heat  (without  artificial  moisture  in  some 
rooms).  (5)  Want  of  provision  for  a  plentiful  supply  of  fresh  air.  (6)  Poor 
light.  (7)  Carbon  monoxide  gas,  and  excessive  amounts  of  carbon  dioxide 
from  respiration  and  combustion.  Carding,  (i)  Dust  (abundant  and 
continuous  where  old  methods  of  card  shipping  are  in  use).  (2)  Infectious 
dust  (dried  sputum).  (3)  Want  of  provision  for  a  plentiful  supply  of  fresh 
air.  (4)  Carbon  monoxide  gas,  and  excessive  amounts  of  carbon  dioxide  from 
respiration  and  combustion. 


THE   TEXTILE   AND   ALLIED    INDUSTRIES  65 1 

Card  Stripping. — The  introduction  of  the  "dustless  cotton  card  stripping 
apparatus,  "2  invented  and  placed  on  the  market  in  191 1,  prevents  an  unusual 
and  excessive  amount  of  cotton  ''fly"  and  fine  dust  (not  yet  removed  from 
the  cotton)  from  flying  in  the  air  of  the  carding  room.  In  fact,  the  strip- 
ping device  is  fitted  so  perfectly  to  the  card  on  the  one  end  and  to  a  dust- 
tight  patented  machine  on  the  other  that  practically  no  dust  escapes  into  the 
air  of  the  workroom.  The  use  of  the  apparatus  requires  a  little  more  time 
than  the  ordinary  stripping  roll  consumes,  but  the  extra  time  is  more  than 
offset  by  the  improved  sanitary  conditions  in  the  workroom  and  by  the  better 
health  of  the  employees.  This  card  stripping  apparatus  is  now  in  use  in 
many  cotton  mills  in  Massachusetts  and  throughout  New  England  and  the 
Southern  States. 

Artificial  Moisture. — Reference  has  been  made  to  the  introduction  and 
use  of  artificial  moisture.  In  England  certain  localities  have  yielded  climatic 
conditions  which  have  been  very  favorable  to  the  manufacture  of  textile 
fabrics.  In  this  country  within  recent  years  systems  of  artificial  humidifica- 
tion  have  been  installed  in  most  of  the  mills  less  favorably  located  in  order  to 
increase  the  moisture  in  the  air  of  the  rooms.  While  a  certain  amount 
of  moisture  gives  an  elasticity  and  smoothness  to  the  fibers  which  may  then 
be  carded,  combed,  spun  and  woven  more  easily  and  evenly,  too  much  moist- 
ure is  not  only  detrimental  to  many  of  the  operations  but  is  also  injurious  to 
the  workers. 

The  two  simplest  but  practically  obsolete  methods  of  introducing  mois- 
ture into  mill  rooms  are  (i)  the  water  sprinkling  or  "digging"  method,  by 
sprinkling  water  upon  the  floor  and  (2)  the  use  of  steam.  The  methods  now 
generally  in  use  are  evolved  from  one  or  the  other  of  these  practices.  They 
include  the  spray  moistures  in  a  large  variety  of  patterns.  The  tj^Des  most 
commonly  found  in  Massachusetts  mills  are  those  in  which  a  spray  is  pro- 
jected directly  into  the  air  in  the  room.  A  discussion  of  the  bacterial  con- 
dition of  the  air  in  picker,  carding,  spinning  and  weaving  departments  of 
certain  cotton  mills,  with  tables  showing  average  results  of  examination  of 
air  in  these  departments,  is  contained  in  a  report  by  H.  W.  Clark  to  the 
Massachusetts  State  Board  of  Health  in  1913  on  "A  Study  of  the  Hygienic 
Condition  of  the  Air  in  Textile  Mills  with  Reference  to  the  Influence  of 
Artificial  Humidification." 

In  spite  of  the  modern  method  of  humidification  the  writer  found,  from 
an  investigation  of  a  very  large  number  of  cotton  mills,  that  the  raising  of 
humidity  was  done  in  a  very  unworkmanlike  manner.  Scarcely  any  effort 
was  made  on  the  part  of  most  manufacturers  to  ascertain  the  definite  condi- 
tions with  respect  to  heat  and  moisture  favorable  to  weaving  and  spinning, 
by  the  use  of  accurate  thermometers  and  hygrometers.  In  the  great  major- 
ity of  instances  where  hygrometers  were  used  the  instruments  were  untrust- 
worthy. The  writer  is  of  the  opinion  that  most  of  the  men  in  mills,  who  have 
the  care  of  the  ordinary  stationary  wet  and  dry  bulb  thermometer  for  de- 


652        ETIOLOGY   AND    PROPHYL.AXIS    OF   OCCUPATIONAL   DISEASES 

termining  the  atmospheric  humidity,  either  neglect  to  keep  them  in  order  or 
fail  to  take  accurate  records. 

A  few  agents  or  superintendents  of  mills  have  made  extensive  inquiries 
as  to  what  degree  of  humidity  for  a  given  temperature  constitutes  the  best 
working  conditions.  These  men  have  used  the  self-registering  hygrometer, 
or  psychrometer,  and  the  "sling  hygrometer"  with  very  promising  results; 
and  one  of  them  stated  that  "for  quickly  and  accurately  determining  the 
actual  moisture  and  temperature  conditions  of  a  room,  the  sling  hygrometer 
leaves  little  to  be  desired  for  mill  use." 

The  diseases  with  which  cotton  mill  operatives  appear  to  be  most  com- 
monly afflicted,  and  from  the  effects  of  which  become  seriously  impaired  in 
health  are:  pulmonary  tuberculosis,  pneumonia,  asthma^frequently  with 
bronchitis,  influenza  and  rheumatism.  In  Massachusetts  the  reduction  in  the 
death  rate  from  pulmonary  tuberculosis  during  recent  years  has  been  much 
less  in  the  four  textile  centers,  Fall  River,  Lowell,  New  Bedford,  and  Law- 
rence, than  in  the  State  in  general.  Other  factors,  however,  enter  into  the 
question  as  to  the  harmfulness  of  the  cotton  industry  to  health  and  its  effects 
on  length  of  life.  The  sanitation  in  all  of  these  cities  is  not  on  the  same  plane. 
The  homes  and  immediate  surroundings  of  the  workers  are  not  alike.  The 
personal  characteristics,  nationality,  physique,  educational  opportunities  and 
habits,  differ;  moreover,  we  have  no  accurate  statistics  covering  the  illnesses 
of  cotton  workers  in  connection  with  the  particular  kind  of  work  done  and  the 
length  of  time  spent  at  that  kind  of  work.  There  is  probably  no  industry  to- 
day that  we  know  less  about  in  its  effects  on  health  and  longevity  than  the 
textile  industry,  of  which  the  cotton  industry  is  a  principal  part.  While  we 
may  reason  from  death  returns  that  tuberculosis  and  pneumonia  are  the 
diseases  most  prevalent  among  mill  operatives,  does  it  follow  that  these 
diseases,  known  to  be  prevalent  among  so  many  different  types  of  workers 
in  various  industries,  are  the  direct  result  of  mill  life  and  work?  The  writer 
considers  this  one  of  the  most  important  and  far-reaching  problems  in  the 
study  and  researches  of  occupational  hygiene. 

Woolen  and  Worsted  Manufacture.* — This  industry  includes  the 
manufacture  of  woolen  and  worsted  goods,  the  production  of  wool  felt  goods 
and  of  wool  hats.  During  the  last  U.  S.  census  175,171  wage  earners  were 
employed  of  whom  13  per  cent,  were  spinners,  22.2  per  cent,  weavers  and 
64.7  per  cent,  in  other  capacities.  The  number  of  wage  earners  included 
75,869  females  and  9576  children  under  16  years  of  age.  The  general 
processes  employed  in  the  manufacture  of  woolen  and  worsted  goods  are 
very  much  of  the  same  character  as  in  the  cotton  textile  industry. 

The  most  important  hygienic  features  are  connected  with  the  sorting, 
carding,  combing,  spinning,  weaving,  dyeing  and  finishing  processes. 

The  wool  is  usually  sorted  by  females  on  benches  with  perforated  tops 
or  on  tables  covered  with  wire  mesh,  through  which  dust  and  dirt  falls  into 

*By  George  M.  Kober. 


THE    TEXTILE    AXD    ALLIED    INDUSTRIES  653 

a  box  beneath.  This  operation  is  of  special  interest,  not  only  on  account 
of  its  dusty  nature,  which  gives  rise  to  catarrhal  affections,  but  also  because 
of  the  danger  from  anthrax  infection.  Of  261  cases  of  anthrax  infection 
tabulated  by  Dr.  Legge  88  occurred  in  this  industry.  The  disease  was 
formerly  even  more  common  than  now  and  was  commonly  spoken  of  as 
"  woolsorter's  disease."  Those  engaged  in  wool  scouring  especially  in  the 
extraction  of  oil  by  means  of  sulphur  chloride,  carbon  disulphide,  benzine, 
benzol,  etc.,  are  exposed  to  these  industrial  poisons.  Sulphuric  or  hydro- 
chloric acid  are  also  used  in  the  cleaning  process. 

Manufacture  of  Carpets  and  Rugs.*— The  weaving  of  carpets  and 
rugs  involves  many  of  the  same  dusty  processes  incident  to  the  textile  in- 
dustry in  general.  The  materials  employed  differ,  however,  more  widely  as 
wool,  cotton  and  hemp  or  jute  are  used  singly  or  in  combination.  The 
wool  used  in  this  industry  is  generally  of  a  short  and  coarse  fiber,  and  it 
is  quite  probable  that  the  amount  of  dust  is  greater  in  carpet  and  rug  mills 
than  in  other  branches  of  the  textile  industry.  In  some  establishments  the 
raw  materials  are  picked,  carded,  twisted  and  spun,  while  in  other  factories 
the  yarns  have  been  prepared  elsewhere.  The  bales  of  yarn  are  opened  and 
the  yarn  is  dusted  by  machinery,  which  gives  rise  to  considerable  dust  and 
is  especially  injurious  if  poisonous  dyes  have  been  used.  The  State  of 
Massachusetts  in  1900  limited  the  use  of  arsenical  pigments  to  o.io  grain 
per  square  yard,  and  aniline  dyes  have  superseded  the  use  of  chrome  dyes 
to  a  great  extent.  The  operation  of  carpet  weaving  is  not  only  a  very  dusty 
process  but  requires  great  care  in  the  prevention  and  detection  of  flaws  and 
skips.  After  leaving  the  loom  the  carpet  or  rug  is  carefully  inspected,  sheared 
and  brushed.  The  shearing  process  is  especially  a  dusty  operation.  The 
work  of  carpet  weaving  is  hard,  but  the  death  rates  compare  favorably  with 
those  of  other  textile  workers.  The  Enghsh  statistics  show  that  the  compara- 
tive mortality  was  873,  which  is  8  per  cent,  below  the  standard.  Consump- 
tion was  22  per  cent,  in  excess  of  the  normal  and  other  diseases  of  the  respira- 
tory system  were  11  per  cent,  in  excess.  Hoffman's  statistics  based  upon  155 
deaths  among  carpet  and  rug  makers,  show  that  23.9  per  cent,  were  from 
consumption,  and  16.9  per  cent,  from  other  diseases  of  the  respiratory  organs. 
Thompson  has  seen  a  few  cases  of  anthrax  among  weavers  of  rugs  and  car- 
pets in  eastern  New  York. 

Flax  and  Linen.* — Employees  in  flax  textiles  are  apparently  more  exposed 
to  dust  and  various  diseases  of  the  respiratory  organs  than  those  in  woolen 
mills.  This  is  especially  true  of  the  men  or  boys  who  attend  the  "heckling" 
machines. 

The  work,  especially  the  spinning,  is  often  carried  on  in  a  hot  and  humid 
atmosphere,  which  predisposes  to  diseases.  According  to  Oliver^  recent 
employees  suffer  from  so-called  ''mill  fever,"  which  lasts  from  2  to  3  days  and 
is  characterized  by  rise  of  temperature,  malaise,  nausea,  vomiting  and  head- 

*  By  George  M.  Kober. 


654        ETIOLOGY   AND   PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

ache.  This  affection  is  attributed  to  the  disagreeable  odor  given  ofif  by  the 
oil,  and  the  combined  effects  of  heat  and  humidity. 

Accidents  from  machinery,  "flat-foot,"  varicose  veins,  and  ulcers  from 
prolonged  standing,  are  not  infrequent.  Flax  workers  are  very  liable  to 
suffer  from  eczema  and  also  from  a  peculiar  ulceration  of  the  skin,  caused  by 
the  irritant  effect  of  lactic  and  butyric  acids  which  are  used  in  some  establish- 
ments, in  a  solution,  during  the  spinning  of  the  thread.  The  drippings  from 
this  solution  sometimes  get  on  the  barefeet  of  the  employees  and  produce 
similar  effects  (Hazen).  These  ulcers  have  been  repeatedly  observed  by 
Gilbert  in  Belgium,  but  not  by  Dr.  Purdon  of  Belfast,  indicating  that  the 
process  very  likely  differs  in  different  countries  and  establishments.  Dr. 
Purdon  describes  a  peculiar  skin  eruption  which  affects  the  arms  and  face  of 
the  workers  who  remove  the  full  bobbins  from  the  spinning  frames.  The 
eruption  resembles  smallpox  and  is  attributed  to  the  irritant  effects  of  flax, 
water  and  oil.  Callosities  on  the  index-fingers  of  "hecklers,"  and  painful 
affections  of  the  nails  of  the  great  toe  in  men  who  work  barefooted,  are  not 
infrequent. 

The  phthisis  death  rate  in  Belfast^  with  its  30,000  persons  engaged  in 
the  linen  industry  was  4.1  per  1000,  against  1.4  for  the  whole  of  England 
and  Wales,  and  2.1  for  Ireland.  According  to  Schuler  and  Burkhardt  1000 
linen  spinners  furnish  annually  221.6  cases  of  sickness;  1000  weavers  202.7. 
Female  operatives  suffer  even  more,  the  sick  rate  being  249.5  ^^^  334-4  for 
the  respective  occupations. 

Lace  Workers.* — An  excellent  description  of  the  manufacture  of  lace 
by  machinery  will  be  found  on  page  746,  Bulletin  of  Labor  No.  79,  1908. 
This  industry,  which  is  chiefly  carried  on  in  Nottingham,  consists  of  lace 
making  proper,  finishing,  including  dressing,  gauffering,  bleaching  and  dye- 
ing. Arlidge  considers  the  process  of  "gauffering"  as  particularly  injurious, 
chiefly  because  the  machines  employed  are  heated  by  gas.  Excessive 
heat  and    humidity  are  injurious  factors  in  some  of   the  departments. 

This  occupation  involves  little  or  no  exposure  to  dust  and  the  death 
rate  from  consumption  among  lace  workers  in  Great  Britain  is  somewhat 
below  the  average  frequency  in  other  branches  of  textile  manufacture. 
But  they  show  a  marked  excess  in  the  mortality  from  cancer,  alcoholism, 
diseases  of  the  liver,  nervous  and  circulatory  diseases.  The  Leipsic  sta- 
tistics show  a  sickness  rate  of  620  days  per  100  male  workers  and  910  for 
female  workers,  with  a  low  mortality  hazard  of  0.35  per  cent,  and  0.54  per 
cent,  respectively. 

Manufacture  of  Cordage,  Twine,  Jute,  Etc.*— This  industry  includes: 
(i)  the  manufacture  of  rope,  binder  twine,  cordage;  (2)  gunny  cloth  and  other 
goods  in  which  jute  is  the  principal  material;  (3)  crash  towelling,  linen  thread, 
etc.,  made  chiefly  from  flax;  and  (4)  the  manufacture  of  nets  and  seines. 
During  the  last  U.  S.  census  27,214  persons,  including  1763  children,  were 

*  By  George  M.  Kober. 


THE    TEXTILE    AND   ALLIED    INDUSTRIES  655 

engaged  in  this  industry,  of  whom  51.8  per  cent,  were  males  and  43.2  per 
cent,  females. 

The  primitive  methods  of  rope  making  have  been  displaced  by  machine 
work.  But  it  is  extremely  doubtful  whether  this  has  been  of  benefit  to  the 
operatives.  The  raw  material  arrives  at  the  factory  in  bales,  which  on 
opening  and  shaking  apart,  emit  considerable  quantities  of  dust.  After 
shaking,  ordinary  jute  and  hemp  are  run  through  softening  machines,  in 
which,  according  to  the  Massachusetts  State  Board  of  Health,^  "they  are 
moistened  with  an  emulsion  of  oil  and  water,  preparatory  to  carding.  Old 
rope,  gunny  bagging  and  twine  are  run  through  machines  which  pick  the 
fibers  apart  as  a  preliminary  to  other  processes.  Opening,  picking,  soften- 
ing and  carding  are  exceedingly  dusty  processes,  and  the  dust  is  very  irri- 
tating to  the  air  passages.  A  fairly  large  proportion  of  the  operatives  show 
the  effects  of  their  employment,  looking  pale  and  sickly." 

Apart  from  dust  inhalation,  the  employment  of  boiling  tar  in  the  manu- 
facture of  rope  and  oakum,  may  produce  tar  itch.  Skin  rashes,  caused  by 
the  oil  and  coloring  matter  employed,  are  not  uncommon.  English  statistics 
show  that  the  mortality  from  consumption  among  cordage  makers  is  ex- 
cessive at  ages  20-34  and  55  years  or  over.  The  general  death  rate  is  also 
in  excess  of  the  normal  mortality  of  occupied  males.  Hoffman's*  statistics 
based  upon  109  deaths  from  all  causes  among  cordage  makers,  show  that 
25.7  per  cent,  were  caused  by  consumption  and  8.3  per  cent,  by  other  re- 
spiratory diseases.  The  statistics  of  the  infirmary  at  Dundee  which  is  the 
seat  of  the  jute  industry  in  England  show  an  undue  prevalence  of  lobar 
pneumonia  among  the  operatives.  Oliver^  states  that  deafness  caused  by 
excessive  noises,  and  impacted  ear  wax,  is  a  common  complaint.  He  also 
refers  to  the  dwarfiness  and  anaemic  condition  of  the  Dundee  employees,  and 
justly  dwells  upon  the  baneful  effects  of  female  and  child  labor  in  this  in- 
dustry. The  same  author  mentions  the  fact  that  several  cases  of  tetanus 
were  traced  to  the  raw  material  imported  from  India,  the  organism  having 
been  recovered  from  the  machinery  dust. 

Dye  Works.* — Cases  of  poisoning  by  dyes  are  becoming  less  frequent 
in  this  country  on  account  of  educational  methods  and  proscriptive  regu- 
lations against  the  employment  of  arsenical  coal-tar  dyes.  Occasional 
cases  still  occur  from  arsenite  of  sodium,  which  is  used  for  fixing  coal-tar 
dyes  in  Turkey  red  dye  works,  and  also  from  orpiment  dyes,  which  give  off 
arseniuretted  hydrogen  gas  and  are  likewise  productive  of  eczematous  affec- 
tions of  the  skin.  Much  harm  also  results  from  the  employment  of  lead  salts, 
especially  in  calico  printing,  and  from  the  use  of  chromate  of  lead  in  dyeing 
yarns,  etc.  Cazaneuve*  has  found  10  per  cent,  of  chromate  of  lead  in  cotton 
yarn  and  as  high  as  18  per  cent,  in  woolen  yarn,  and  in  the  dust  of  rooms 
where  the  yarn  was  worked  up  44  per  cent.  The  women  who  handle 
and  pull  the  yarn  are  literally  covered  with  yellow  dust,  and  quite  a  number 

*By  George  M.  Kober. 


656        ETIOLOGY   AND   PROPHYLAXIS    OF   OCCUPATIONAL   DISEASES 

suffer  from  the  combined  effects  of  lead  and  chrome.  Clayton^  has  described 
a  number  of  cases  of  lead  poisoning  in  this  industry.  Among  other  inju- 
rious mordants  are  antimony  and  tin  compounds. 

Ammonia  is  also  used  in  some  of  the  dye  works.  Cases  of  poisoning 
in  aniline  black  dyeing  have  been  reported  by  Deardon^"  of  Manchester. 
Neisseria  cites  the  Report  of  a  Medical  Inspector  in  England  upon  the  effects 
of  aniline  oil  in  black  dyeing  works,  and  also  the  effects  upon  the  skin  of 
chromic  acid  and  the  bichromates  in  these  establishments.  He  examined 
200  employees,  many  of  whom  suffered  from  anaemia,  headache,  digestive 
derangements,  heart-burn,  dizziness,  palpitation  of  the  heart,  loss  of  will 
power,  excessive  mucous  secretions  and  grayish  discoloration  of  the  lips, 
all  of  which  symptoms  were  attributed  to  the  toxic  effects  of  aniline.  Of 
82  persons  employed  in  the  padding,  washing  and  drying  processes,  34  per 
cent,  had  gray  lips,  20  per  cent,  were  anaemic  and  14  per  cent,  suffered  from 
the  effects  of  chrome. 

Apart  from  exposure  to  industrial  poisons,  the  work  is  exhausting  espe- 
cially in  summer  on  account  of  the  heat  and  humidity;  it  is  also  sloppy 
work  and  hence  colds,  catarrhal,  rheumatic  and  neuralgic  affections  are  not 
uncommon. 

Preventive  Measures. — The  use  of  all  poisonous  dyes  and  mordants 
should  be  prohibited.  Until  this  is  accomplished  the  following  safeguards 
recommended  by  the  British  Medical  Inspector  should  be  carried  out.  i. 
Mechanical  suctional  ventilation,  (a)  at  the  machines  where  the  cloth  is 
being  dyed,  (b)  at  the  machines  where  the  cloth  passes  through  the  bi- 
chromate solution,  and  (c)  at  points  where  there  is  danger  from  chromate 
dust.  2.  Protective  clothing  and  frequent  washing  of  the  working  suits. 
3.  Dressing-rooms  and  lockers  for  street  clothing.  4.  Suitable  wash  rooms. 
5.  Special  lunch  rooms. 

The  use  of  respirators  in  dusty  processes  and  of  vaseline  to  the  skin  are 
indicated.  All  dye  works  should  have  cement  floors,  well  drained,  wooden 
slats  to  stand  upon  during  wet  work,  and  good  overhead  ventilation. 

An  examination  of  58  workers  in  the  cotton  belt  and  rope  industry  found 
three  cases  of  tuberculosis  and  also  predisposing  working' conditions.  ^^ 

REFERENCES 

1  For  illustrated  description  of  processes  in  Cotton  Industry,  see  Bull.  U.  S.  Dept.  of  Labor, 

Bureau  of  Labor  Statistics,  No.  127. 

2  For  illustration  see  Practical  Hygiene,  Harrington-Richardson,  page  650. 
•■^  Oliver.^ — Diseases  of  Occupation,  London,  1908. 

■•  Ferris,  G.  H. — Journal  of  State  Medicine,  March,  1895. 

^  Report  of  the  Alassachusetts  State  Board  of  Health  upon  the  Sanitary  Condition  of 
Workshops,  Factories,  etc.,  1907,  page  46. 

"  Hoffman. — Bulletin  Bureau  of  Labor,  No.  79,  1908. 

'  Oliver. — Diseases  of  Occupation,  London,  1908,  page  257. 

*  Zeitschft  f.  off.  Gesundheitspfl.,  cited  by  Rambousek,  London,  1913,  page  58. 

"  Clayton.— Brit.  Med.  Journ.,  1906,  Vol.  I,  page  310. 
'"  Deardon. — British  Med.  Jour.,  1902,  Vol.  II,  page  750. 

"  Neisser. — Internat.  Ubersicht  iiber  Gewerbehygiene,  Berlin,  1907,  pages  74-75. 
!-•  Robinson,  D.  E.,  and  Wilson,  J.  G.— U.  S.  Public  Health  Bulletin  No.  73,  March,  1916. 


CHAPTER  IX 
THE  BOOT  AND  SHOE  INDUSTRY 

BY  GEORGE  M.  KOBER,  M.  D.,  Washington,  D.  C. 
Edge  Trimming,  Bottom  Scouring  and  Finishing,  etc.     Preventive  Measures. 

The  Boot  and  Shoe  Industry. — During  the  last  U.  S.  census  215,923 
persons  were  employed  in  this  industry  of  whom  70,449  were  females  and 
8099  children  under  16  years. 

The  old-time  occupation  of  shoe  and  boot  making  has  assumed  a  different 
character  during  the  last  three  or  four  decades  by  the  estabhshment  of  large 
factories,  many  of  which  are  model  workshops.  But  even  now  this  occu- 
pation, and  certainly  all  repair  work,  is  still  carried  on  in  a  primitive  way 
as  a  home  industry,  and  when  thus  conducted  we  may  expect  to  find 
an  undue  prevalence  of  diseases  of  the  respiratory  organs,  and  other  affec- 
tions ingendered  by  unfavorable  working  conditions.  Faulty  position  is 
responsible  for  the  round  shoulders,  and  pressure  of  the  iron  last  against  the 
chest  in  the  operation  of  burnishing,  etc.,  is  the  cause  of  a  peculiar  deformity 
of  the  chest,  characterized  by  a  marked  depression  of  the  breast  bone  and 
cartilaginous  ends  of  the  ribs.  Callosities  of  the  upper  surface  of  the  right 
thigh  caused  by  pressure  of  the  clamps  and  strap  are  of  frequent  occurrence. 

Diseases  of  the  heart,  according  to  Sternberg,^  are  unusually  common, 
15.5  per  cent,  against  an  average  of  10.8  per  cent,  in  other  occupations. 
Both  he  and  Koelsch^  attribute  this  to  venous  congestions  caused  by  the 
stooped  position  and  also  to  intemperate  habits.  Injuries  followed  by  septic 
infections  and  diseases  of  the  skin  are  not  infrequent.  Scabies  appear  to  be 
unusually  prevalent  among  the  shoemakers  of  Vienna  amounting  to  38.9 
per  cent,  against  10.8  per  cent,  in  other  occupations.  Among  399  cases  of 
tetany  described  by  v.  Frankl-Hochwart^  179  occurred  in  shoemakers. 
This  affection  is  characterized  by  bilateral  tonic  spasms  of  the  muscles  of  the 
hand  and  wrist  and  often  assumes  an  epidemic  character,  which  Koelsch'^ 
attributes  to  unclean  habits  and  close  sleeping  quarters.  Cases  of  plumbism 
caused  by  the  pernicious  habit  of  holding  tinned  tacks  in  the  mouth  have 
been  reported.  Prolonged  standing  may  develop  flat-foot  and  varicose 
veins;  sedentary  habits  tend  to  induce  constipation  and  hemorrhoids.  The 
Leipsic  statistics  show  a  sickness  rate  of  642  days  per  100  shoemakers  and 
a  mortality  hazard  of  0.68  per  cent. 

In  the  manufacture  of  boots  and  shoes  in  large  establishments  the  work- 
ing conditions  are  generally  speaking  more  favorable.  There  are  a  numl)er 
of  processes,  some  of  which  are  less  harmful  than  others.  The  following  is 
42  657 


658        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

a  condensed  statement  from  the  Report  of  the  State  Board  of  Health  of 
Massachusetts.^ 

Cutting  Department. — In  this  department  the  first  process  of  making  the 
shoe  is  begun.  The  men  who  cut  the  leather  and  lining  material  for  the 
uppers  with  sharp  knives  by  hand  or  machines,  are  more  or  less  exposed  to 
injuries.     The  work  calls  for  good  light. 

Fitting  or  Stitching. — The  re-enforcement  of  parts  with  cotton  cloth  is 
done  by  machine  work,  usually  by  boys  and  girls  who  may  occupy  a  standing 
or  sitting  position.  The  same  is  true  of  cutting  tongues  and  eyelets  stays, 
and  the  perforation  of  tips.  The  work  of  joining  the  linings  to  the  uppers  is 
done  by  machines  operated  by  women.  The  edges  of  the  vamps,  quarters 
and  tips  are  covered  by  girls  and  women  with  a  cement  of  rubber,  dissolved 
in  naphtha,  to  the  fumes  of  which  the  operators  are  exposed,  especially  when 
open  cans,  instead  of  patent  closed  containers  with  automatic  omitters  are 
used.  The  machines  for  eyelets  are  usually  operated  by  men,  and  the 
buttonhole  machines  by  women.  The  vamps  are  stitched  to  the  quarters 
by  men  and  women;  the  latter  usually  work  in  lighter  stock. 

In  the  sole  leather  and  stock  fitting  department  the  stock  is  cut  out  by 
men  and  channelled  and  the  soles  and  uppers  are  ready  to  go  to  the  making 
department,  which  includes,  lasting,  heeling  and  finishing  and  numerous  sub- 
divisions. Most  of  the  work  is  performed  by  men  and  boys  in  a-  standing 
position. 

Lasting. — In  this  department  the  upper  part  of  the  shoe  and  inner  sole 
are  fitted  over  a  suitable  last  and  the  outer  sole  is  stitched  on.  Among  the 
injurious  factors  should  be  mentioned  the  possibility  of  mercurial  poisoning 
in  persons  attending  the  sole  leather  stitching  machines,  if  mercury  is  em- 
ployed, as  a  lubricant,  as  it  frequently  is,  in  the  Blake  machines.  Several 
mechanical  processes  connected  with  the  lasting  department  also  involve 
exposure  to  heat  from  the  warming  racks  and  the  possibility  of  wood  alcohol 
and  benzine  poisoning  from  the  shellac  and  cement  employed.  After  stitch- 
ing on  the  outer  sole  the  shoe  is  ready  to  receive  the  heel. 

Bottoning  and  Finishing. — In  the  manufacture  of  shoe  heels  the  workers 
are  exposed  to  the  inhalation  of  considerable  quantities  of  leather  dust  and 
also  to  the  fumes  of  wood  alcohol  and  naphtha,  from  the  shellac  and  cement 
which  are  employed.  The  heels  are  usually  rough  and  larger  than  the  re- 
quired size,  and  are  turned  over  to  the  heel  trimmer  or  shaver.  The  heel- 
trimming  machine  requires  watchful  care  to  avoid  injury  or  a  spoiled  product. 
Painful  callosities  frequently  develop  on  the  outer  and  upper  surface  of  the 
last  two  joints  of  the  left  fore-  and  middle  fingers  of  the  operator.  In  "heel 
scouring"  a  felt  wheel  faced  with  carborundum  or  sand,  moulded  paper  and 
cloth  is  used. 

Edge  trimming  of  the  sole  of  a  shoe  is  also  done  by  machine  work  and 
involves  exposure  to  considerable  fine  dust  which  should  be  removed  by 
exhaust  ventilation. 


THE  BOOT   AND    SHOE   INDUSTRY  659 

Bottom  Scouring  and  Finishing. — In  this  process  the  sole  and  face  of  the 
heel  receive  a  smooth  surface  by  means  of  a  wheel  covered  with  sandpaper 
or  carborundum.  In  the  process  of  Naumkeag-Buffing  the  sole  and  shank  is 
brought  into  contact  with  a  revolving  wheel  covered  with  emery  cloth,  or 
carborundum,  and  involves  exposure  to  a  mixture  of  animal,  mineral  and 
vegetable  dust.  The  same  is  true  of  heel  and  breast  scouring.  In  the  final 
polishing  process,  blacking  is  applied,  and  revolving  bristle  brushes  and 
cloth  wheels  are  employed.  Wax  is  also  put  on  the  polishing  wheels.  Apart 
from  exposure  to  dust,  the  process  is  very  liable  to  produce  inflammatory 
conditions  of  the  hands. 

As  a  result  of  exposure  to  dust  composed  of  leather,  sand,  emery,  car- 
borundum, bristles,  lint,  shellac,  resin  and  wax,  it  is  not  surprising  that  dis- 
eases of  the  respiratory  passages  should  be  quite  common.  According  to 
Dr.  J.  Beatty,*  Medical  Officer  of  Health  of  Northampton  in  England,  the 
phthisis  death  rate  for  boot  and  shoemakers  was  2.59  per  1000,  against  a 
normal  average  of  2.08  for  the  whole  population.  In  the  City  of  Brockton, 
Mass.,  out  of  167  deaths  among  shoemakers  42  or  25.1  per  cent,  were  caused 
by  pulmonary  consumption  and  11.4  per  cent,  by  other  lung  diseases.  In 
Lynn  in  297  deaths  among  shoemakers  21.9  per  cent,  were  caused  by  con- 
sumption and  ID. I  per  cent,  by  other  respiratory  diseases.  Hoffman's 
statistics,^  based  upon  1930  deaths  among  boot  and  shoemakers,  371  or  19.2 
per  cent,  were  caused  by  consumption  and  14.4  per  cent,  by  other  diseases 
of  the  lungs.  The  excess  was  most  pronounced  at  ages  between  25  to  34 
when  out  of  every  100  deaths  from  aU  causes  50.3  per  cent,  were  from  con- 
sumption against  a  normal  expected  proportion  of  31.3. 

Three  thousand  and  seven  employees  in  the  boot  and  shoe  industry  in  Cincinnati  were 
examined,^  and  only  47  cases  or  1.56  per  cent,  of  the  workers  presented  evidence  of  tuber- 
culosis. Some  processes,  especially  heel  polishing  and  bottom  sanding,  unless  adequately 
safeguarded,  undoubtedly  predispose  to  tuberculosis.  In  the  factories  visited,  powerful 
blowers  were  provided  to  carry  off  the  dust  thus  formed. 

Preventive  Measures. — No  state  board  of  health  has  accomplished  better 
results  than  that  of  the  State  of  Massachusetts  which,  by  frequent  exhibits 
of  photographs  contrasting  sanitary  and  insanitary  processes,  has  stimulated 
most  gratifying  improvements  in  the  working  conditions  of  this  and  other 
industries®  (see  Hanson's  Monograph).  There  is  every  reason  to  believe 
that  all  the  health  hazards  connected  with  this  industry  can  be  removed  by 
efficient  factory  sanitation,  with  special  reference  to  the  removal  of  dust  and 
fumes. 

REFERENCES 

*  Sternberg,  M. — Weyl's  Handbuch  dor  Arbeiterkrankh.,  Jena,  1908. 
2  Koelsch. — Krankheit  und  Soziale  Lage  Miinchen.,  191 2. 

2  Report  of  the  State  Board  of  Health  upon  the  Sanitary  Condition  of  Factories,  Work- 
shops, etc.,  1907.     Hygiene  of  the  Boot  and  Shoe  Industry  in  Massachusetts,  191 2. 
^  Hoffman,  F.  L. — Bulletin  Bureau  of  Labor,  No.  82,  May,  1909. 

*  Exhibits  of  the  Prudential  Insurance  Company  of  America,  191 2. 
^  U.  S.  Labor  Bulletin  No.  154,  1914. 

^  Robinson,  D.  E.,  and  Wilson,  J.  G.— U.'S.  Public  Health  Bulletin  No.  73,  March,  1916. 


CHAPTER  X 
TAILORS,  GARMENT  AND  LAUNDRY  WORKERS 

BY  GEORGE  M.  KOBER,  M.  D.,  Washington,  D.  C. 

Tailors  and  Garment  Workers.— This  occupation,  like  that  of  shoe  and 
bootmakers,  has  also  undergone  marked  changes  as  regards  general  working 
conditions,  and  the  old- type  tailor  shop  can  be  found  only  in  small  towns 
and  villages  and  in  connection  with  repair  shops.  It  is  well  known  that 
weakhngs  generally  seek  this  occupation,  and  it  is  not  surprising  that  the 
constrained  position  of  the  body,  which  interferes  with  free  expansion  of  the 
chest,  should  not  only  favor  the  development  of  skeletal  deformities,  but  also 
predispose  to  pulmonary  diseases.  While  most  of  the  work  is  now  carried 
on  in  large  establishments,  the  shops  are  frequently  not  much  better  than  the 
homes,  or  tenement  shops,  as  regards  air-space,  ventilation,  lighting  and 
general  sanitation.  According  to  Dr.  Geo.  M.  Price,  of  1800  shops  in  the 
cloak  and  suit  industry  examined  in  New  York  in  191 1,  only  3.83  per  cent, 
had  any  special  means  of  ventilation.  The  efforts  of  the  joint  board  of 
sanitary  control  to  improve  the  conditions  and  the  health  of  the  workers  in 
this  industry,  in  New  York,  have  attracted  the  attention  of  the  United 
States  Public  Health  Service  and  the  authorities  are  now  conducting  a  special 
examination  of  the  working  conditions  and  the  effect  of  the  employees.  A 
similar  investigation  was  carried  on  by  Dr.  Linenthal  of  the  Board  of  Health 
of  the  State  of  Massachusetts  as  early  as  1908.^  He  investigated  the  manu- 
facture of  men's  ready-made  clothing,  the  manufacture  of  men's  custom  made 
clothing  and  the  manufacture  of  ladies  garments.  The  result  of  the  inspec- 
tion showed  that  the  industry  was  carried  on  for  the  most  part  in  neglected 
buildings.  Stairs  and  hallways  were  as  a  rule  dirty  and  in  many  instances 
the  water-closets  were  foul  and  filthy.  The  working  rooms  were  found 
unclean,  the  walls  and  ceilings  dirty  and  in  need  of  a  coat  of  whitewash,  and 
the  windows  were  often  so  dusty  as  to  be  almost  opaque.  The  disgusting 
and  dangerous  habit  of  spitting  on  the  floor  or  on  heaps  of  rags  was  observed 
in  almost  every  establishment  visited.  Dr.  Linenthal  very  justly  attributes 
the  main  cause  of  the  insanitary  conditions  in  the  clothing  industry  to  the 
contract  or  sweat  shop  system.  The  competition  among  the  contractors 
being  extremely  keen,  their  earnings  often  less  than  that  of  the  employees, 
it  is  but  natural  that  little  or  no  attention  is  given  to  matters  of  sanitation. 
The  shops  operated  directly  by  the  manufacturers  were  generally  in  a  very 
satisfactory  condition,  and  efforts  toward  improving  existing  conditions  in 
the  insanitary  shops  of  Boston  have  been  fruitful. 

660 


TAILORS,    GARMENT   AND    LAUNDRY   WORIOERS  66l 

Conditions  are,  if  anything,  worse  when  the  work  is  carried  on  in  tenement 
homes,  where  one  room  often  serves  as  a  workroom,  hving  room,  dining  room 
and  kitchen,  and  long  hours  and  child  labor  are  the  rule,  in  order  to  eke  ou 
a  mere  existence.  The  effects  of  overcrowding,  overwork,  "speeding  up" 
underfeeding,  constrained  position  and  exposure  to  dust,  and  carbon  mon- 
oxide from  ironing  stoves  and  leaky  gas  tubing  are  plainly  evinced  by  the 
pallor  and  anaemia  of  the  operatives  and  the  undue  prevalence  of  tuberculosis 
and  neurasthenia. 

Epstein^  states  that  43.7  per  cent,  of  the  morbidity  among  tailors  is 
caused  by  pulmonary  tuberculosis,  and  that  of  266  post-mortem  examinations 
in  118  male  and  148  female  tailors,  performed  at  the  Munich  Pathological 
Institute,  123  or  46.2  per  cent,  died  from  consumption.  The  records  of  the 
Milan  Clinic  and  of  the  tuberculosis  clinics  in  this  country  likewise  show  an 
undue  prevalence  of  tuberculosis  in  garment  workers.  According  to  Schwab' 
fully  25  per  cent,  of  7000  garment  workers  in  St.  Louis  suffered  from  neuras- 
thenia. Cases  of  gastric  catarrh,  hemorrhoids,  varicose  veins,  and  ulcers 
and  diseases  of  the  female  genital  organs  are  also  quite  common  and  are 
probably  caused  by  improper  food  and  pelvic  congestions,  incident  to  sedentary 
habits,  constrained  positions,  foot-power  sewing  machines,  etc.  Lateral 
curvature  of  the  spine,  occupation  neuroses  and  visual  defects  are  likewise 
frequently  observed. 

Cases  of  industrial  lead  poisoning  from  the  use  of  silk  thread,  which  had 
been  weighted  by  a  solution  of  sugar  of  lead  have  been  reported  by  Eulenberg 
and  Teleky,  Cases  of  eczema  contracted  while  handling  silk  fabrics  and 
tarlatan  dyed  with  arsenic  containing  aniline  colors,  picric  acid,  Schweinfurth 
green,  etc.,  and  even  symptoms  of  systemic  poisoning  from  arsenic,  have 
been  reported  by  Layet  and  Epstein.  Hayhurst  in  his  Ohio  Survey  of 
1914  refers  to  the  use  of  benzine  in  association  with  cleaning  and  cementing 
processes,  carried  on  in  the  same  quarters. 

A  recent  investigation  by  the  U.  S.  Public  Health  Service  (see  Bulletin 
No.  71,  May,  1915),  based  upon  a  physical  examination  of  2107  male  and 
1000  female  garment  workers  in  the  City  of  New  York,  shows  the  following: 
Among  male  garment  workers,  the  pressers  have  the  most  robust  physique. 
Among  female  garment  workers  no  striking  physical  differences  were  ob- 
served in  the  various  class  of  workers.  Tuberculosis  is  the  most  prevalent 
disease;  a  postural  influence  may  be  discerned,  since  finishers  (among  males) 
show  the  greatest  percentage  of  faulty  postures. 

Apart  from  tuberculosis,  the  number  of  cases  of  emphysema  of  the  lungs, 
chronic  bronchitis  and  chronic  catarrhal  conditions  of  the  nasopharynx 
indicates  that  the  presence  of  suspended  matter  (woolen  "fly.")  in  the  air 
of  the  workshops  may  be  a  factor  in  the  development  of  these  diseases. 
Other  defects  and  diseases  were  defective  vision,  flat  feet,  defective  teeth 
and  pyorrhea,  nervous  affections,  particularly  neurasthenia,  defective 
hearing,  digestive  derangements  and  habitual  constipation  due  to  dietetic 


662        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

errors  and  faulty  postures.  Only  about  2  per  cent,  of  those  examined  were 
free  from  defects,  but  a  large  part  of  these  defects  are  believed  to  be  due 
to  ignorance  or  neglect  of  personal  hygiene. 

The  Leipsic  Insurance  statistics  show  a  sickness  rate  of  715  days  per  100 
workers  per  annum  and  a  mortality  hazard  of  0.88  per  cent.;  for  dressmakers 
and  seamstresses  the  sickness  rate  is  933  days,  and  the  mortality  hazard 
0.50  per  cent. 

Preventive  Measures. — The  fact  that  during  the  last  census  year  393,439 
persons,  including  230,395  women  and  6252  persons  under  16  years  of  age, 
were  engaged  in  the  clothing  industry  in  the  United  States  indicates  suffi- 
ciently that  every  effort  should  be  made  to  improve  the  working  conditions 
of  this  class  of  wage  earners.  This  can  be  done  only  by  absolute  prohibition 
of  all  manufacturing  in  tenement  houses,  the  abolition  of  the  contract  system 
and  sweat  shops,  and  the  enactment  and  rigid  enforcement  of  law^s  concern- 
ing factory  sanitation.  Even  the  small  establishments  and  repair  shops 
should  be  placed  under  sanitary  control,  not  only  to  safeguard  the  health 
of  the  employees,  but  also  for  the  prevention-of  communicable  diseases  which 
may  be  spread  through  the  medium  of  infected  clothing. 

Laundry  Workers. — We  have  no  statistics  of  the  number  of  persons  actu- 
ally engaged  in  laundry  work.  The  last  United  States  census  shows  that 
124,214  persons  were  engaged  in  the  steam  laundry  industry,  of  whom  81,833 
were  females  and  675  persons  under  16  years  of  age;  about  75  per  cent,  of 
the  wage  earners  were  engaged  in  laundries  in  which  the  hours  of  employ- 
ment ranged  between  54  to  60  hours  per  week. 

Those  who  have  read  "The  Long  Day,"  "The  True  Story  of  a  New  York 
Working  Girl  as  Told  by  Herself,"  or  who  have  critically  studied  the  work- 
ing conditions  in  steam  laundries,  realize  the  hardships  incurred  by  this 
class  of  workers.  The  work  naturally  includes  a  number  of  operations. 
Some  of  the  employees  are  engaged  in  opening  the  various  bundles  and 
marking  each  piece,  if  not  already  marked,  and  in  separating  the  "flat" 
from  the  "starched"  work.  This  work  is  regarded  as  quite  disagreeable,  as 
every  piece  has  to  be  handled.  The  Medical  Officer  of  Stockport,^  in  Eng- 
land, refers  to  the  use  of  aniline  oil  in  laundries  as  a  source  of  poisoning  to 
the  females  engaged  in  marking  the  clothes. 

After  being  sorted,  the  clothes  are  placed  in  washing  machines  and 
churned  for  about  20  minutes  in  hot  water  with  soap  or  washing  powder. 
The  bleaching  powders  are  quite  irritating  to  the  skin  and  eczema  of  the 
hands  and  arms  is  not  infrequent.  The  washing  machines  are  generally  run 
by  men,  and  only  a  small  proportion  of  the  washing  is  done  by  hand  in  open 
tubs.  After  removal  from  the  washing  machines  the  clothes  are  placed 
in  a  centrifugal  machine,  commonly  called  the  wringer,  which  quickly  re- 
moves the  excess  of  water,  and  the  articles  are  placed  on  racks  and  rolled 
into  the  steam-heated  drying  chamber.  From  the  dryer  the  flat  work  goes 
directly  to  the  mangles,  where  it  is  ironed  and  folded;  the  "starched  work" 


TAILORS,    GARMENT    AND    LAUNDRY   WORKERS 


663 


is  generally  machine  starched,  and  the  ironing  is  done  partly  by  machine 
and  in  part  by  hand.  The  work  in  summer  is  especially  exhausting  on  account 
of  the  combination  of  heat  and  humidity.  The  temperature  in  the  mangle 
and  ironing  department  is  often  over  ioo°F.  but  much  commendable  progress 
has  been  made  in  the  alleviation  of  these  conditions,  certainly  in  this  country, 
by  the  introduction  of  high  studded  rooms  and  forced  ventilation.  The 
watery  vapors  from  the  drying  chambers  are  speedily  carried  away  by  ex- 
haust fans,  and  in  nearly  every  well-appointed  laundry  we  find  good  overhead 


Fig.  43. — Laundry  workers.  The  flat-work  ironing  machine  is  provided  with  an  ex- 
cellent overhead  hood  connected  by  suction  pipes  with  an  exhaust  fan.  (Photo  supplied 
by  Hanson  for  the  Mass.  State  Board  of  Health.) 

ventilation  and  revolving  fans.  Cases  of  arsenic  and  gas  poisoning  have  been 
reported  as  a  result  of  exposure  to  the  fumes  of  coal-burning  ironing  stoves, 
or  defective  gas  connections.  Accidents  in  American  laundries  are  not  very 
common,  as  the  machines  are  all  well  guarded.  According  to  the  Medical  In- 
spector of  the  State  of  Massachusetts,^  in  1907  in  one  estabhshment  employ- 
ing 95  persons,  two  accidents  occurred  in  5  years;  in  another  employing  54 
persons  two  slight  accidents  due  to  carelessness  had  been  recorded  in  15 
years.  Sir  Thomas  Oliver^  states  that  in  1906,  301  accidents  were  reported  in 
England — 46  males  and  255  females.  He  also  cites  two  fatal  cases  of  tetanus 
which  occurred  in  workers  apparently  in  the  same  laundry:  one,  a  girl  of  15, 


664        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

ran  a  splinter  in  her  finger  while  washing  up  the  floor  of  the  lunch  room; 
the  other  was  a  man  who  received  injuries  while  trying  to  start  the  engine. 
Oliver  thinks  it  probable  that  the  floor  of  the  mess  room  was  infected  by 
the  soiled  boots  of  the  workers. 

It  is  rather  remarkable  that  recent  text-books  make  no  reference  to  the 
possibility  of  contracting  infectious  diseases  in  the  laundry  business.  The 
Massachusetts  investigation^  on  this  point,  even  among  "markers"  proved 
negative,  and  the  general  health  conditions  among  the  employees  were  also 


Fig.  44. — Laundry  workers.  The  flat-work  ironing  machine  is  not  protected  by  an 
exhaust  system  and  the  steam  disposes  through  the  room  causing  excessive  heat  and 
humidity.     (Photo  supplied  by  Hanson  for  the  Mass.  State  Board  of  Health.) 


found  to  be  very  satisfactory.  Uffelmann^  in  discussing  the  spread  of  typhoid 
fever  and  cholera  mentions  a  number  of  instances  where  the  disease  was  con- 
veyed to  washerwomen,  apparently  through  infected  bed  and  body  linen. 
It  is  quite  possible  that  the  danger  referred  to  is  greater  in  hand  or  home 
laundries. 

Much  of  the  work  in  laundries  is  carried  on  in  a  standing  position;  hence 
varicose  veins,  leg  ulcers  and  flat-foot  are  quite  common.  Among  other 
prevalent  diseases  should  be  mentioned  chlorosis,  diseases  of  the  digestive 
organs,  gastric  catarrh,  gastric  ulcer,  cardialgia,  constipation,  enteroptosis, 
retroflexion  of   the  uterus,  dysmenorrhea,  rheumatism,  hysteria  and  neu- 


TAILORS,    GARMENT   AND    LAUNDRY   WORKERS  665 

ralgia,  while  catarrhal  affections  and  diseases  of  the  respiratory  organs,  in- 
cluding pulmonary  tuberculosis,  are  also  quite  common.  As  a  typical 
occupational  disease  Margoniner*  describes  a  synovitis  of  the  long  extensor 
tendons  of  the  right  arm,  beginning  about  the  medial  end  of  the  metacarpal 
of  the  thumb  and  extending  midway  up  the  forearm;  another  favorite  loca- 
tion of  this  affection  is  in  the  shoulder-joint.  The  women  engaged  in  iron- 
ing and  washing  by  hand  are  most  frequently  afflicted.  Paraesthesia,  or  a 
peculiar  tingling  itching  of  the  fingers,  is  occasionally  observed  in  ironers. 
Among  165  female  employees  under  observation  for  3  years  in  Brooklyn, 
N.  Y.,  there  were  1876  cases  of  sickness,  among  them  436  cases  of  gastric 
diseases,  328  of  dysmenorrhea,  124  colds,  55  of  sore-throat,  36  of  neuralgia 
and  31  of  rheumatism.^  The  Leipsic  statistics  show  a  morbidity  rate  of  979 
days  per  100  ironers  and  washers  and  a  mortality  hazard  of  0.71  per  cent. 

Preventive  Measures. — Reasonable  working  hours  and  all  the  pre- 
cautions already  pointed  out  in  reference  to  ventilation  and  safety  devices 
for  moving  machinery,  sloping  concrete  floors,  good  drainage,  slatted  plat- 
forms or  mats,  rubber  aprons  and  boots  for  all  sloppy  work. 

In  examining  2648  employees  in  the  clothing  industry  in  Cincinnati,  Robinson  and  Wil- 
son^"  found  39  cases  or  1.17  per  cent,  of  tuberculosis.  According  to  Hayhurst  there  were 
228  deaths  from  tuberculosis  among  18,793  wage  earners  in  the  clothing  industry  of 
Ohio  between  1910-1912.  These  rates  are  higher  than  among  workers  in  brass,  copper, 
foundry  and  machine  shop  products.  The  in\-estigators  point  out  that  a  much  greater 
percentage  of  the  workers  in  the  clothing  industry  fall  within  the  age  period,  when  tuber- 
culosis is  most  frequent  and  that  many  weaklings  seek  this  occupation.  Low  wages, 
"speeding  up,"  and  poor  home  conditions  are  also  mentioned  as  predisposing  factors. 

Among  199  laundry  workers  four,  or  2  per  cent,  of  those  examined,  were  suffering  from 
tuberculosis,  but  not  caused  by  the  working  conditions.  Even  the  markers  and  listers 
who  handle  the  dirty  clothes  consider  their  work  free  from  the  risk  of  infectious  diseases. 
The  only  thing  the  workers  fear  is  body  lice,  which  they  guard  against.  ^lany  years  ago 
a  case  of  smallpox  was  sometimes  contracted  from  the  clothes,  but  never  any  other  diseases. 
The  older  employees  also  testify  to  the  improved  working  conditions  made  during  the  last 
decade,  in  labor-saving  machinery,  slatted  floors,  exhaust  fans  for  the  removal  of  steam, 
and  reasonable  working  hours.  In  former  years  as  one  woman  expressed  it,  "the  girls 
were  more  faded  looking  than  the  clothes  they  were  washing." 

REFERENCES 

1  Report  of  the  Work  of  State  Inspectors  of  Health,  Xov.,  1908. 

2  Epstein. — Weyl's  Handbuch  d.  Arbeiterkrankh.,  Jena,  1908,  page  410. 
^  Schwab,  Sidney  I. — Am.  Labor  Assoc.  Review,  Vol.  I,  No.  i,  191 1. 

*  Neisser. — Internat.  Ubersicht  iiber  Gewerbehygiene,  Berlin,  1907,  pages  72-75- 

5  Report  of  the  Massachusetts  State  Board  of  Health  upon  the  Sanitary  Condition  of 

Factories,  Workshops,  etc.,  1907,  page  143. 
^  Oliver,  Thomas.— Diseases  of  Occupation,  London,  1908,  page  387. 
^  Uffelmann,  J. — Handbuch  der  Hygiene,  Wien  und  Leipzig,  1890. 
^Weyl's  Handbuch  der  Arbeiterkrankh.,  Jena,  1908,  page  426. 
9  Klink,  Jane  S.— Proceed.  Ac.  Polit.  Science,  N.  Y.,  Jan.,  19 12;  Vol.  II,  No.  2. 
"  Robinson,  D.  E.,  and  Wilson,  J.  G.— U.   S.  Public  Health   Bulletin   No.  73,  March, 
1916. 


CHAPTER  XI 
THE  RAG,   SHODDY  AND  PAPER  INDUSTRY 

BY  GEORGE  M.  KOBER,  M.  D.,  Washington,  D.  C. 
Shoddy.     ^Manufacture  of  Wall-paper.     Cardboard  and  Paper-box  Workers. 

The  Rag  Industry— Rag  sorting  is  an  old  industry  and  the  work  is 
generally  performed  by  women,  whose  duty  is  primarily  to  divide  the 
rags  into  Hnen,  cotton  and  woolen  rags  after  which  they  are  baled.  All 
bales  of  rags  are  opened  at  the  mill  and  the  contents  are  placed  in  a 
beating  or  thrashing  machine  which  separates  the  rags  and  shakes  them 
thoroughly.  This  process  is  attended  by  the  escape  of  more  or  less  dust 
and  the  quantity  naturally  varies  with  the  cleanhness  of  the  stock. 

The  rags  are  conveyed  from  the  duster  or  thrasher  through  a  chute  to 
the  sorting  room,  where  they  are  picked  over  by  women  who  sort  out  all 
cotton,  hnen  and  silk  mixtures,  and  remove  buttons,  whalebones,  rubber, 
buckles  and  other  foreign  matter.  The  sorting  tables  have  a  box-like  top, 
lined  at  the  bottom  with  wire  meshing  through  which  dust  and  fine  particles 
escape  to  receptacles  below. 

It  has  been  held  for  a  long  time  that  the  germs  of  infectious  diseases, 
like  smallpox,  anthrax,  cholera,  scarlet  fever,  tuberculosis,  diphtheria,  and 
septic  germs  may  cling  to  body  and  bedclothes  and  prove  a  source  of  danger 
to  employees  in  the  rag  and  paper  industry.  The  danger,  while  perhaps 
overrated,  is  nevertheless  real  and  would  be  much  more  evident,  if  federal 
legislation  did  not  prevent  the  importation  of  rags  without  previous  disin- 
fection. Some  of  the  states  also  require  evidence  of  successful  vaccination 
in  persons  engaged  in  the  rag  industry,  or  those  employed  in  the  manufacture 
of  paper  from  foreign  and  domestic  rags. 

Shoddy  is  made  from  woolen  rags.  For  this  purpose  the  rags  are  treated 
in  a  large  vat  with  dilute  sulphuric  or  hydrochloric  acid,  which  destroys 
whatever  vegetable  or  cotton  fiber  there  may  be  present  and  leaves  the  wool 
fiber  intact.  This  process  is  known  as  carbonizing  and  may  cause  injury 
from  exposure  to  acid  fumes,  unless  the  process  is  carried  on  in  so-called 
carbonizing  stoves  which  are  ventilated  and  connected  with  coke  condensers. 
Rambousek^  considers  it  essential  that  only  acids  free  from  arsenic  be  em- 
ployed on  account  of  the  danger  from  arseniureted  hydrogen.  The  rags 
are  next  drained,  spread  over  steam  pipes  and  dried  in  a  confined  space,  at  a 
temperature  of  ioo°.  This  involves  exposure  to  acid  fumes,  which  are 
generally  guarded  against  before  the  removal  of  the  dried  rags  by  thorough 

666 


THE    RAG,    SHODDY   AND   PAPER   INDUSTRY  667 

ventilation  and  exhaust  fans.  The  rags  are  next  washed  and  run  through 
"pickers"  which  reduce  them  to  a  wool  of  short  fiber,  which  is  mixed  with 
new  wool,  spun  into  yarn  and  manufactured  into  cheap  cloth.  The  grinding 
or  picking  process  is  extremely  dusty  and  persons  new  to  the  work  are  liable 
to  develop  so-called  "shoddy  fever,"  which  clinically  resembles  an  attack  of 
influenza.  Chronic  affections  of  the  upper  air  passages  are  also  quite 
common.  During  the  last  census  this  industry  afforded  employment 
to  2320  persons,  of  whom  480  were  females. 

The  Paper  Industry. — During  the  last  census  the  paper  and  wood  pulp 
industry  afforded  employment  to  81,473  persons  of  whom  10,557  were  females 
and  154  children  under  16  years  of  age.  The  material  from  which  paper  is 
made  includes  rags,  burlap,  old  paper,  and  wood  pulp.  The  rags  are  sub- 
jected to  a  number  of  processes  for  the  purpose  of  cleaning  and  disintegration, 
some  of  which  have  already  been  alluded  to.  The  beating,  thrashing  and 
chopping  process  is  carried  on  by  machines.  In  the  observation  of  about  80 
establishments,  the  Massachusetts  Board  of  Health  found  that  where  the 
cleanest  grade  of  rags  were  being  handled  practically  no  dust  was  observed, 
but  with  the  usual  grade  of  stock,  no  matter  what  kind  of  duster  or  thrasher 
or  chopper  is  used,  a  considerable  amount  of  dust  is  evolved  and  in  spite 
of  exhaust  fans  and  dust  flues  some  dust  will  escape.  The  men  engaged 
in  the  collection  and  baling  of  this  dust  are  usually  provided  with  respirators. 
The  material,  after  passing  through  the  chopping  machines,  is  conveyed  by 
an  endless  belt  to  the  kettle  room  where  it  is  boiled,  with  the  addition  of 
lime,  usually  in  a  "rag  rotary,"  by  means  of  steam  under  pressure.  After 
thorough  cooking  the  material  is  placed  in  the  "washer;"  it  is  then  bleached 
by  means  of  chloride  of  lime  and  placed  in  a  draining  vault.  When  suffi- 
ciently dry  it  goes  to  the  "beater,"  with  perhaps  some  wood  pulp,  where  it 
undergoes  further  comminution;  it  is  then  transferred  to  a  large  tank  known 
as  the  "machine  chest,"  where  it  is  thoroughly  mixed,  diluted,  and  stored,  and 
from  which  it  passes  as  needed  to  the  paper-making  machines. 

The  occupation  is  evidently  inimical  to  health.  Of  4857  German  opera- 
tives reported  by  Uffelmann^  2437  or  50.2  per  cent,  were  annually  taken 
sick;  the  morbidity  fluctuated  from  9  per  cent,  to  112  per  cent,  in  different 
establishments;  there  were  287  injuries;  about  34  per  cent,  of  those  engaged 
in  the  handling  of  dry  rags  suffered  from  diseases  of  the  respiratory  organs, 
and  only  21.9  per  cent,  of  those  engaged  in  other  processes.  Chronic  bronchitis 
and  emphysema  of  the  lungs,  impacted  ear  wax,  and  granular  inflammation 
of  the  eyeHds  are  not  uncommon  among  the  older  employees.  In  addition 
to  the  danger  from  dust  inhalation  including  also  alum  and  resin  dust,  the 
possibility  of  infection  with  the  virus  of  smallpox,  scarlet  fever,  and  the  germs 
of  tuberculosis,  anthrax,  cholera  and  malignant  oedema  cannot  be  ignored. 
There  is  also  danger  from  the  use  of  chloride  of  lime  for  bleaching  purposes, 
from  the  employment  of  toxic  colors,  confining  lead  or  arsenic,  and  the  addi- 
tion to  the  paper  pulp  of  lead-containing  substances.     In  the  production  of 


668        ETIOLOGY   AND   PROPHYLAXIS    OF   OCCUPATIONAL   DISEASES 

wood  pulp  by  the  sulphite  cellulose  process  there  is  danger  from  escape  of 
sulphur  dioxide  from  the  sulphur  stoves  or  from  the  boilers. 

Preventive  Measures. — Greater  attention  should  be  paid  to  the  construc- 
tion and  interior  arrangement  of  establishments  for  the  rag,  paper  and  shoddy 
industry.  All  dusty  processes  should  be  carried  on  in  separate  rooms, 
partitioned  ofif  tightly  from  adjoining  rooms  where  less  dusty  processes  are 
carried  on.  Efficient  exhaust  ventilation  is  of  the  utmost  importance  for  the 
removal  of  dust  and  fumes.  The  addition  of  poisonous  color  pigments  and 
lead-containing  substances  to  paper  pulp  should  be  prohibited.  Disinfec- 
tion of  rags  and  re  vaccination  of  employees,  suitable  work  suits  including 
in  the  wet  processes  rubber  boots  and  aprons,  and  facilities  for  personal 
cleanliness  should  be  insisted  upon. 

Manufacture  of  Wall-paper. — In  making  wall-paper  the  paper  is  first 
passed  through  troughs  containing  colored  solutions  for  the  ground  work, 
it  then  passes  through  machines  to  receive  patterns  and  different  colors. 
Formerly  there  was  considerable  risk  from  the  employment  of  arsenite  of 
copper  and  lead  pigments;  their  use  has  been  prohibited  in  some  countries 
and  replaced  by  vegetable  or  aniline  colors.  The  employment  of  bronzing 
powders,  mica  and  wool  dust  involves  exposure  to  irritant  forms  of  dust  which 
must  be  guarded  against  by  exhaust  ventilation.  The  temperature  in  the 
printing  department  often  ranges  between  90°  and  ioo°F.  even  in  cold 
weather. 

Cardboard  and  Paper-box  Workers. — The  Leipsic  insurance  statistics 
show  that  this  class  of  workers  has  the  highest  morbidity  rate  among  84 
occupations,  viz.,  1574  days  of  sickness  per  100  workers  per  annum  and  a 
mortality  hazard  of  1.06  per  cent.  There  is  nothing  in  the  manufacturing 
process  which  explains  these  hazards,  unless  the  work  is  carried  on  as  a  home 
industry  by  youthful  workers  and  without  special  precautions.  Apart  from 
machine  accidents  and  dust  the  character  of  stock  employed  is  important. 
If  the  paper  happens  to  be  colored  with  arsenical,  lead  or  chrome  pigments 
there  is  danger  from  metallic  poisoning,  especially  in  the  practice  of  sticking 
on  labels  or  loose  edges,  after  licking  them  with  the  tongue.  This  pernicious 
habit  was  formerly  quite  common  not  only  in  paper-box  factories,  but  in 
many  other  industries  in  which  adhesive  labels  are  used.  As  a  result  the  so- 
called  "stamp  licker's  tongue,"  characterized  by  a  polished  tip  and  small 
ulcers  on  the  tongue  and  mouth,  was  quite  common. 

Since  much  of  the  adhesive  material  used  is  of  animal  origin,  it  is  possible 
that  the  ulcers  are  of  septic  origin;  at  all  events  they  offer  an  excellent  portal 
of  entry  for  septic  germs  and  hence  account  for  the  frequent  involvement  of 
the  submaxillary  glands.  Hayhurst^  beheves  that  there  is  danger  from  lead 
poisoning,  in  labelling  fresh  paint  cans. 

Much  of  this  label  licking  is  done  by  frail  little  girls,  and  the  loss  of  saliva 
and  its  effect  upon  the  digestive  functions  can  be  judged  by  the  fact  that, 
according  to  Miss  Squire,*  Factory  Inspector  of  Great  Britain,  the  Httle  girls 


THE   RAG,    SHODDY   AND   PAPER   INDUSTRY  669 

employed  in  labelling  reels  of  sewing  silk  and  skeins  and  balls  of  embroidery 
"moisten  the  adhesive  labels  by  the  mouth,  sometimes  to  the  number  of  30 
gross  a  day  or  more." 

Preventive  Measures. — It  is  evident  that  the  use  of  mechanical  con- 
trivances and  dampers  to  replace  the  dangerous  process  should  be  made 
obligatory. 

Robinson  and  Wilson^  examined  47  male  and  245  female  employees  in 
four  Paper  Box  factories  in  Cincinnati  and  found  no  cases  of  tuberculosis. 
The  investigators  found  nothing  particularly  hazardous  in  the  work  except 
the  fact  that  it  was  nearly  all  piecework.  The  dust  was  adequately  removed 
by  the  blower  system.  This  gratifying  account  presents  a  striking  contrast 
to  the  morbidity  rates  of  the  Leipsic  workers  (see  page  668). 

Among  855  persons  engaged  in  the  manufacture  of  Playing  Cards  only 
three  cases  of  tuberculosis  or  0.35  per  cent,  were  found.  The  plant  was  new, 
located  in  the  suburbs  with  spacious  grounds,  excellent  light  and  ventilation 
and  general  welfare  work.  As  a  result  the  investigators  report  "very  little 
illness  among  the  employees  and  this  was  in  no  way  attributable  to  the 
occupation." 

REFERENCES 

^  Rambousek,  J. — Industrial  Poisoning,  London,  1913,  pages  156,  336. 
^  Uffelmann,  J. — Handbuch  der  Hygiene,  Wien,  Leipzig,  1890,  page  824. 
'  Hayhurst,  E.  R. — Industrial  Health  Hazards  and  Occupational  Diseases  in  Ohio,  Feb- 
ruary, 1915. 
^  Squire. — Oliver's  Dangerous  Trades,  London,  1902. 
5  Robinson,  D.  E.,  and  Wilson,  J.  G.— U.  S.  Public  Health  Bulletin,  Xo.  73,  March,  1916. 


CHAPTER  XII 
FARMERS,  GARDENERS,  PLANTERS  AND  FARM  LABORERS 

BY  GEORGE  M.  KOBER,  M.  D.,  Washington,  D.  C. 

Farmers,  Gardeners,  Planters  and  Farm  Laborers. — The  general  death 
rate  for  1900  in  the  manufacturing  and  mechanical  industries  of  the  United 
States  was  13.8  per  1000  and  the  consumption  rate  2.6,  or  18.8  per  cent,  of 
the  mortality  from  all  causes. 

The  farming  population  furnished  a  mortality  rate  of  17.6  per  1000  and 
a  consumption  rate  of  only  1.5,  or  9.5  per  cent,  of  the  mortality  from  all 
causes.  Other  diseases  of  the  lungs  are  also  less  frequent.  The  same  is 
true  of  diseases  of  the  circulatory,  urinary,  digestive  and  nervous  system; 
and  the  accident  liability  is  also  below  the  average.  While  this  serves  to 
emphasize  the  advantages  of  an  out-door  life,  it  cannot  be  said  that  this  occu- 
pation is  wholly  free  from  danger.  The  long  working  hours  and  hardship 
and  exposure  to  all  kinds  of  weather,  cannot  fail  to  prove  injurious,  and  as  a 
result,  colds,  catarrhal  affections  of  the  eyes,  nose,  and  throat,  rheumatism, 
and  neuralgia  are  by  no  means  infrequent,  especially  in  men  who  work  in 
green  houses  and  are  exposed  to  abrupt  changes  in  temperature.  Much  of  the 
work,  such  as  transplanting,  grafting,  weeding,  and  cultivation  with  hand 
tools,  is  performed  in  a  stooping  or  kneeling  position,  which  is  liable  to  cause 
lumbago,  congestive  headaches,  nose  bleed  and  distortion  of  the  femur.  Of 
58  cases  of  coxa  vara  observed  by  Bernhart^  49  belonged  to  the  agricultural 
classes. 

Loth^  states  that  while  on  the  whole  the  morbidity  rates  are  more  favor- 
able, the  diseases  are  generally  more  acute,  the  illness  more  severe,  and  the 
mortality  rate,  except  from  consumption,  is  actually  above  the  average  of 
most  of  the  other  occupations. 

It  is  generally  held  that  cancer  of  the  skin  is  more  common  among 
farmers  and  gardeners,  on  account  of  lack  of  cleanliness,  but  Loth  could 
not  confirm  this  from  his  experience  with  the  truck  farmers  of  Erfurt.  Among 
the  diseases  communicable  from  animals  to  men,  to  which  farmers  and  stock- 
men are  exposed,  should  be  mentioned,  foot  and  mouth  disease,  glanders, 
anthrax,  bovine  tuberculosis,  and  lumpy  jaw  or  actinomycosis.  Since  tet- 
anus or  lock  jaw  is  a  typical  soil  disease,  wounds  and  abrasions  are  more 
liable  to  infection  in  this  class  of  workers. 

Diseases  of  the  skin  caused  by  contact  with  poison  ivy,  sumach,  and 
the  primrose,  and  the  affections  produced  by  the  mower  mite  (leptus  au- 
tumnalis),  the  pediculoides  ventricosis  (or  wheat  bug)  and  the  harvest  bug  or 

670 


FARMERS,    GARDENERS,    PLAXTERS    AXD    FARM    L.\BORERS  67 1 

mite  {leptus  irritans)  which  burrow  under  the  skin,  causing  itching  and 
irritation,  are  occasionally  met  with.  The  mites  infest  especially  goose- 
berries and  hyacinth  bulbs  and  ma\'  also  cause  conjunctivitis  by  dust  in- 
fection. Other  sources  of  ophthalmia  are  beards  of  grain,  spears  of  grass, 
twigs,  leaves,  chaflF,  distribution  of  artificial  manure,  fine  hair-like  processes 
from  hop  leaves  (hop-pickers'  ophthalmia) .  Cases  of  arsenical  poisoning  have 
been  reported  from  the  use  of  Paris  green  as  an  insecticide. 

Statistics  cited  by  Neisser  appear  to  indicate  an  undue  prevalence  of 
miscarriages  in  farmer's  wives.  Harrington  calls  attention  to  the  fact 
that  monotony  of  life  is  a  potent  factor  in  mental  breakdown,  as  evidenced 
by  the  frequency  of  insanity  in  farmers  and  farmers'  wives  in  sparcely  settled 
regions. 

Among  the  diseases  spread  by  means  of  human  fecal  matter  or  night 
soil  should  be  mentioned  t^.'phoid  fever,  dysentery,  and  other  infectious 
intestinal  diseases.  We  have  learned  only  in  recent  years  what  an  im- 
portant role  uncinariasis,  or  hook-worm  infection,  plays  in  the  loss  of  life, 
impairment  of  health,  efficiency,  and  earning  power  of  the  tillers  of  the  soil 
in  almost  every  part  of  the  globe. 

A  correct  idea  of  the  economic  aspect  of  this  disease  may  be  gained 
by  reference  to  the  chapter  on  Animal  Parasites  written  by  Dr.  Ashford, 
who,  in  1899,  was  the  first  to  demonstrate  that  the  hook-worm  is  the  cause 
of  the  anaemic,  dropsical,  and  debilitated  condition,  and  the  high  death  rate, 
of  the  peasant  population  of  Porto  Rico.  In  1902  Professor  Stiles  pointed 
out  that  the  same  parasite  is  like\\'ise  crippling  the  South. 

Mr.  Rose^  of  the  Rockefeller  Sanitary  Commission,  through  the  courtesy 
of  the  Department  of  State,  has  been  enabled  to  show  that  the  hook-worm 
infection  belts  the  globe,  in  a  zone  about  66°  wide,  extending  from  about  par- 
allel 36°  north  to  about  parallel  30°  south,  and  that  about  940,000,000  persons 
live  in  46  countries  where  hook-worm  is  prevalent.  It  is  estimated  that  90 
per  cent,  of  the  inhabitants  of  certain  parts  of  Columbia  are  infected;  50 
per  cent,  of  the  total  population  of  British  Guiana,  with  a  higher  percent- 
age among  the  laborers  on  the  sugar  plantations.  In  Dutch  Guiana  the  in- 
fection on  many  plantations  runs  as  high  as  90  per  cent. 

It  is  further  stated  that  50  per  cent,  of  the  coolie  laborers  on  sugar  and 
tea  estates  in  Natal,  and  the  same  percentage  of  the  laboring  population 
in  Egypt,  are  infected;  that  on  many  plantations  in  Ceylon  the  infection 
runs  as  high  as  90  per  cent.;  and  on  the  rubber  plantations  in  the  Malay 
States  from  47-74  per  cent.;  that  of  the  300,000,000  people  in  India  from 60 
to  80  per  cent,  harbor  this  parasite;  that  the  population  of  the  southern  two- 
thirds  of  the  Chinese  Empire  is  involved,  the  infection  among  the  farming 
population  running  as  high  as  70  to  76  per  cent.;  and  that  about  70  per  cent, 
of  the  entire  population  of  American  Samoa  are  infected. 

Preventive  Measures. — When  we  consider  the  vast  number  of  persons 
engaged  in  agricultural  pursuits,  it  is  evident  that  greater  attention  should 


672        ETIOLOGY   AND   PROPHYLAXIS    OF    OCCUPATIONAL  DISEASES 

be  paid  to  their  hygiene.  The  working  hours  at  present  are  excessive  and 
should  be  reduced  to  10  hours  a  day,  which  would  offer  also  opportunities 
to  vary  the  monotony  of  life.  The  diet  is  often  faulty,  especially  the  hot 
biscuits  and  greasy  fried  dishes,  and  should  be  improved.  The  clothing 
should  be  adapted  to  climate  and  seasons,  and  farm  labor  should  not  be  done 
in  bare  feet.  Personal  cleanliness,  frequent  ablutions  of  soiled  hands,  and 
prompt  disinfection  of  wounds  and  abrasions  with  tincture  of  iodine  are 
indicated.  More  attention  should  be  paid  toward  securing  cheerful,  airy, 
sunny,  and  healthful  homes,  the  proper  disposal  of  house  wastes,  and  a  pure 
water  supply. 

No  farm  should  be  without  sanitary  conveniences.  The  Department 
of  Agriculture  has  published  directions  for  the  construction  of  suitable 
privies.  On  account  of  the  possibility  of  infecting  the  water  supply,  wells 
and  privies  should  not  be  dangerous  neighbors.  The  undue  prevalence  of 
typhoid  fever  in  rural  districts  could  be  materially  checked  by  prompt 
disinfection  of  the  stools  of  the  typhoid  patients.  This  is  all  the  more  im- 
portant, since  infection  is  often  conveyed  through  the  milk  supply,  and 
through  vegetables  and  strawberries  raised  in  beds  which  have  been  fertilized 
with  infected  night  soil,  which  may  thus  infect  consumers  residing  elsewhere. 

Danger  from  Carbon  Dioxide  in  Silos. — While  cases  of  fatal  asphyxia  from  carbon  diox- 
ide evolved  as  a  result  of  intramolecular  processes  have  been  reported  among  vintners, 
distillers,  brewers,  yeast  makers,  in  the  holds  of  grain  vessels  and  in  peat  pits,  the  four 
cases  described  by  Hayhurst  and  Scott'  are  the  first  on  record  in  connection  with  workers 
in  silos.  It  is  not  improbable  that  such  accidents  have  occurred  before  and  death  has 
been  attributed  to  other  causes. 

These  four  cases  of  sudden  death  clearly  indicate  the  necessity  of  greater  precaution 
in  the  way  of  ventilation  of  silos,  either  by  open  doors  above  the  level  of  the  silage,  or  as 
suggested  by  Hayhurst  and  Scott  by  the  use  of  unhinged  doors,  which  fall  in  as  the  silage 
settles  below  them,  and  by  open  roofs.  The  authors  state  that  the  gas  can  be  driven  out 
easily  by  using  an  open  umbrella,  bunch  of  hay,  or  a  leafy  branch  of  a  tree  to  promote 
diffusion.  The  extinguishing  of  a  candle  or  lamp  flame  indicates  the  presence  of  dangerous 
volumes  of  CO2.  In  case  of  accident  oxygen  inhalation  and  artificial  respiration  by  means 
of  the  Meltzer  apparatus  should  be  resorted  to. 

REFERENCES 

^Bernhart,  cited  by  Koelsch.— Krankheit  u.  Soziale  Lage,  ist  Liefg.  Miinchen,  1912. 

2  Loth. — Weyl's  Handbuch  d.  Arbeiterkrankh.,  1908. 

3  Rose.— Trans.  15th  Internat.  Congress  on  Hygiene,  Washington,  D.  C,  1913,  Vol.  Ill, 

Part  II,  page  762. 
*  Hayhurst,  E.  R.,  and  Scott,  Ernest.— J.  A.  M.  A.,  Vol.  LXIII,  pages  1570-1572.     Also 
Bull.  Ohio  State  Board  of  Health,  October,  1914,  and  Indust.  Health  Hazards  & 
Occup.  Diseases  in  Ohio,  1915,  pages  394-399. 


CHAPTER  XIII 
THE  LUMBER  INDUSTRY 

BY  GEORGE  M.  KOBER.  M.  D.,  Washington,  D.  C. 

Saw  and  Planing  Mills.  Toxic  Woods:  Sequoia;  Cocobola;  Sabicu;  Satin-wood;  Mexican 
Blue  Gum  and  Indian  Rosewood;  African  Boxwood.  Wood  Preservatives,  Stains 
and  Polishes.  Carpenters  and  Cabinet  Makers.  Piano  and  Organ  Making.  Chair 
and  Rattan  Factories.  Whip  and  Walking  Stick  Makers.  Furniture  Repair 
Shops.     Moulding  and  Picture-frame  Makers.     Preventive  Measures. 

The  Ltimber  Industry. — According  to  the  U.  S.  census  of  1 910  an  average 
of  695,019  wage  earners,  inclusive  of  7959  females  and  5933  children  under  16 
years  of  age,  were  employed  in  this  industry.  The  merchant  saw  mills  af- 
forded employment  to  547,178  persons,  the  independent  planing  mills  em- 
ployed 112,392  wage  earners,  and  the  wooden  packing  box  factories  employed 
35,449  persons.     Most  of  the  women  were  employed  as  cooks,  etc. 

•  According  to  the  report  of  the  Washington  State  Industrial  Insurance 
Commission,  47,400  men  are  employed  in  the  logging  camps  and  lumber  mills 
of  that  State  alone.  During  the  period  from  October  i,  1911  to  September 
I,  1913  there  were  9661  accidents  with  251  fatal  injuries;  990  of  the  injuries 
resulted  in  permanent  partial  disability,  and  8420  in  temporary  disability. 
Among  the  causes  of  accidents  may  be  mentioned  the  folloTvdng:  Falling 
timbers,  lumber,  etc.  Rolling  and  moving  logs,  log  carriages,  handling 
lumber,  timbers,  etc.,  flying  fragments,  axes,  hatchets,  adzes,  crosscut  saws, 
splinters,  power-driven  saws,  planes,  and  wood-working  machines.  During 
the  year  ending  October  i,  1913  there  were  not  less  than  7465  awards  in  this 
industry  in  that  State  amounting  to  8668,793.84. 

Preventive  Measures. — ^The  accident  liability  is  sufficiently  appalling 
to  have  induced  Miss  Boardman  on  behalf  of  the  American  Red  Cross  to  ar- 
range for  first-aid  instruction  in  our  American  lumber  camps.  In  addition 
to  accidents  the  men  are  exposed  to  hard  work,  long  working  hours,  inclem- 
ency of  the  weather  and  very  frequently  also  to  typhoid  and  hook-worm 
infection,  vermin  from  avoidable  insanitary  conditions  of  camps,  food 
supplies,  kitchens,  disposal  of  refuse,  etc. 

Saw  and  Planing  Mills. — In  these  occupations,  hard  work,  exposure  to 
drafts,  high  temperature  in  the  drying  kiln  department,  the  effects  of  in- 
cessant noise  upon  hearing,  the  inhalation  of  dust  from  planing  and  sand- 
papering machines  and  accidents  are  injurious  factors. 

Accident  Liability. — Of  3464  accidents  requiring  workingmen's  compensa- 
tion in  Austria  collected  by  Sternberg,'  1074  were  caused  by  planing  machines, 
283  by  ripping  machines,  1975  by  circular  saws  and  132  by  straight  saws; 
43  673 


674        ETIOLOGY   AND   PROPHYL.\XIS    OF   OCCUPATIONAL   DISEASES 

3029  of  the  injuries  involved  the  fingers,  resulting  often  in  complete  loss  of 
one  or  more  members;  268  involved  the  hands  and  forearm,  and  46  the  eyes, 
mostly  from  flying  fragments  from  the  circular  saws. 

Wood  Workers. — Apart  from  accidents,  intense  noises,  from  ripping  and 
planing  machines,  constrained  position^  causing  the  so-called  "carpenter's 
stoop"  and  exposure  in  certain  processes  to  industrial  poisons,  the  chief  oc- 
cupational risks  are  unfavorable  hygienic  environments,  exposure  to  wood 
dust,  sandpaper  and  sanding  belts.  The  amount  and  character  of  dust  de- 
pends upon  the  process  in  which  it  is  evolved  and  the  character  of  the  wood; 
the  dust  from  hard  wood  is  finer,  harder  and  doubtless  more  irritating  to 
the  respiratory  passages.  Sommerfeld-  gives  the  mortality  rate  from  tuber- 
culosis among  wood  workers  as  6.6  per  1000. 

According  to  Roth^  61.7  per  cent,  of  all  the  deaths  among  the  wood  turners 
in  Berlin  between  1890  and  1897  were  caused  by  consumption;  inflammation 
of  the  skin  and  mucous  membranes  are  also  quite  common  in  this  class  of 
workers  on  account  of  the  use  of  bichromate  and  aniline  stains,  wood  alcohol, 
varnishes,  etc. 

Toxic  Woods. — Workers  in  "sequoia  wood,"  especially  recent  employees, 
are  liable  to  suffer  from  catarrhal  symptoms,  such  as  sneezing,  watering  of 
the  nose,  smarting  of  the  eyes,  irritation  in  the  throat,  coughing,  difiicult 
breathing  and  oppression  in  the  pit  of  the  stomach."* 

"Cocobola  wood"  is  extensively  used  in  the  manufacture  of  tools  and  im- 
plements, especially  for  handles,  and  also  for  bowling  balls.  This  wood 
evolves  a  very  pungent  and  irritating  dust  productive  of  inflammation  of  the 
eyes  and  skin.  Some  persons  become  accustomed  to  its  effects  while  others 
are  obliged  to  discontinue  work  in  that  department.  Similar  observations 
have  been  made  in  Austria  in  connection  with  the  manufacture  of  walking 
sticks  from  "cocobola"  and  other  exotic,  colored  hard  wood.  The  Factory 
Inspector^  also  observed  an  undue  prevalence  of  diseases  of  the  respiratory 
organs  and  insisted  upon  the  introduction  of  mechanical  devices  for  the 
removal  of  dust. 

Dr.  Neisser^  refers  to  a  tool  factory  at  Strassburg  which  in  1904  furnished 
15  cases  of  sickness  out  of  the  20  employees,  with  288  days  loss  of  work; 
among  these  were  six  cases  of  diseases  of  the  lungs,  three  of  the  nose  and 
throat  and  one  of  the  eyes.  In  this  instance  the  authorities  likewise  insisted 
upon  effective  removal  of  the  dust.  Dr.  A.  Nestler^  has  recently  studied  the 
toxic  principle  of  cocobola  wood  and  believes  it  to  be  an  ethereal  oil,  soluble 
in  alcohol  and  benzol  and  to  a  less  extent  in  water. 

Sabicu  wood,  a  product  of  Cuba,  is  said  to  produce  a  "snuffy  dust"  and 
catarrhal  symptoms  of  the  eyes  and  nose.  The  same  is  said  of  the  Japanese 
hard  wood  "tagayasa"  which  in  addition  also  causes  dermatitis  and  a  dark 
brown  gunpowder-like  pigmentation.  The  toxic  action  is  attributed  by 
Iwakawa  to  a  substance  closely  allied  to  chrysarobin  and  like  the  latter 
agent  also  affects  injuriously  the  digestive  and  renal  functions. 


THE    LUMBER    INTDUSTRY  675 

Satin  Wood,  Mexican  Blue  Gum  and  Indian  Rosewood. — The  Medical 
Inspector  of  Great  Britain*  in  1904  reports  a  few  cases  of  a  peculiar  inflam- 
mation of  the  skin  affecting  cabinet  workers  engaged  in  handling  "satin 
wood"  panels  for  decorative  purposes  in  the  smoking  room  of  a  steamer. 
The  dust  frorp  this  wood  {Cloroxylon  Swientenia)  affected  only  the  unpro- 
tected portions  of  the  body,  face,  neck,  ears,  hands  and  wrists.  The  first 
symptoms  consisted  of  an  intense  irritation,  followed  by  heat,  redness,  swell- 
ing and  pain;  at  a  later  stage  the  skin  became  moist  and  peeled  off.  Some  of 
the  workmen  doing  the  same  work  experienced  no  unpleasant  symptoms. 
The  wood  from  East  India  was  found  to  be  more  irritating  than  the  West 
India  variety.  Satin  walnut  appears  to  be  harmless.  Nestler^  has  recently 
succeeded  in  extracting  the  active  principle  consisting  of  a  stearin-like  sub- 
stance soluble  only  in  ether.  A  small  quantity  of  it  placed  in  contact  with 
the  skin  of  the  forearm  produced  in  about  5  hours  a  tensely  swollen  yellowish 
blister  surrounded  by  a  red  area  of  inflammation.  After  the  bursting  of  the 
blister  an  ulcer  remained  which  required  4  weeks  to  heal.  The  dust  of 
"cokus  "wood,  ebony,  teak  and  Mexican  "blue  gum"  is  also  liable  to  cause 
inflammatory  skin  affections.  Teak  wood  also  produces  constitutional 
symptoms  such  as  nausea,  and  vomiting.  Sternberg*  refers  to  "Indian  rose- 
wood" as  a  cause  of  inflammatory  affections  of  the  skin  of  the  face,  fore- 
arms and  hands  in  the  employees  of  one  of  the  Vienna  store  fixture  factories. 

African  Boxwood  (Gonioma  Kamassi). — In  1905  the  Medical  Inspector 
of  Great  Britain^  reported  a  number  of  instances  with  toxic  symptoms 
occurring  among  persons  employed  in  the  manufacture  especially  during  the 
sandpapering  process  of  weaver  shuttles  made  from  African  boxwood. 
Investigation  revealed  the  presence  of  an  alkaloid  in  the  wood  which  acts  as 
a  heart  depressant,  producing  a  slow  and  intermittent  pulse,  also  headache, 
watering  of  the  eyes  and  nose,  feeling  of  sleepiness  and  difficulty  of  breathing. 
Some  of  the  men  were  pale,  weak  and  jaundiced  and  had  precordial  pain, 
nausea,  cold  sweats  and  a  camphor-like  odor  of  the  breath.  Oliver^"  states 
that  Dr.  Young  described  in  1902  symptoms  such  as  inflammation  of  the 
eyes,  dilatation  of  the  pupils,  dryness  of  the  throat  and  catarrhal  conditions, 
lasting  2  or  3  days  in  men  making  rulers  from  Marcaibo  boxwood.  Poison- 
ing by  African  boxwood  is  subject  to  compensation  under  the  British 
Compensation  Act. 

Wood  Preservatives.— Persons  engaged  in  the  impregnation  of  railroad 
ties,  shingles,  etc.,  with  tar  or  creosote  are  liable  to  suffer  from  vesicular  and 
other  skin  eruptions  not  necessarily  confined  to  the  hands  of  the  worker. 

Wood  Stains  and  Polishes.— Reference  has  been  made  on  page  674  to 
the  use  of  bichromates  for  wood  stains,  and  on  page  546  to  the  toxic  effects 
of  red  aniline  used  for  staining  purposes  in  imitation  of  mahogony,  or  to 
impart  to  this  wood  a  richer  color;  similar  instances  are  doubtless  quite  fre- 
quent. In  a  recent  invetigation  at  Budapest  it  was  found  that  the  pro- 
longed working  with  stains  containing  wood  alcohol  may  cause  optic  neuritis. 


676         ETIOLOGY    AND    PROPHYLAXIS    OF    OCCUPATIONAL    DISEASES 

simply  by  the  evaporation  of  the  spirit  and  several  workmen  in  a  cabinet 
factory  were  suffering  from  incipient  atrophy  of  the  optic  nerye.  As  a  result 
of  Dr.  Daifis'^^  investigation,  which  also  revealed  the  presence  of  wood  alcohol 
in  a  few  of  the  most  expensive  liquors,  monthly  inspections  of  the  workmen 
have  been  ordered,  and  it  is  expected  that  more  stringent  legislation  will  be 
enacted. 

The  so-called  "polishers'  itch"  an  eczematous  condition  of  the  hands 
and  arms  is  quite  common  among  wood  polishers.  The  causative  agent 
being  either  petroleum,  parafi&ne  oil,  shellac  dissolved  in  wood  alcohol  or  in 
alcohol  denatured  with  pyridine  bases  or  wood  alcohol.  The  use  of  varnish 
may  give  rise  to  occasional  cases  of  plumbism,  and  Sternberg^^  reports  that 
old  topers  not  infrequently  drink  the  shellac  mixture  leading  to  the  forma- 
tion of  shellac  concretions  in  the  stomach. 

Carpenters  and  Cabinet  Makers. — According  to  Sternberg^*  of  10,071 
male  workers  in  Vienna  during  the  year  1904,  5341  were  taken  sick;  of  these 
1506  or  28.1  per  cent,  suffered  from  tuberculosis  and  other  diseases  of  the 
respiratory  passages.  The  death  rate  from  tuberculosis  in  the  registration 
area  in  the  U.  S.  for  1909  was  10. i  per  cent.  Apart  from  dust  inhalation  this 
class  of  workers  are  liable  to  suffer  from  callosities  and  contracted  tendons 
of  the  palm  of  the  hand  from  the  use  of  the  chisel  and  those  using  hand 
planes  involving  rotary  movements  of  the  wrist  and  forearm  not  infrequently 
develop  occupational  neuroses  and  peculiar  inflammation  of  the  tendons  of 
the  dorsal  surface  of  the  thumb.  Workers  in  parquetry  and  scrapers  of 
floors  are  very  liable  to  develop  inflammation  of  the  bursa  in  front  of  the 
kneecap,  with  accumulation  of  fluid  therein  (housemaid's  knee).  Faulty 
positions  and  unsuitable  work  benches  naturally  favor  the  development  of 
spinal  curvature  and  other  deformities.  Continuous  standing  predisposes 
to  varicose  veins,  ulcers  and  "flat-foot,"  affecting  especially  the  left  side. 
(See  also  wood  stains  and  polishes.) 

Piano  and  Organ  Making.— These  industries  include  a  great  number 
of  separate  processes;  of  hygienic  interest  are  those  connected  with  dust 
production,  the  inhalation  of  bronze  and  exposure  to  wood  alcohol  in  the 
varnishing  and  polishing  department.  Cases  of  lead  poisoning  have  been 
reported  among  solderers,  varnishers  and  bronzers  of  piano  frames  and  also 
in  men,  who  work  on  pipe  organs.  Other  hazards  are  acid  dipping  and  elec- 
troplating, brazing  and  welding. 

Chair  and  Rattan  Factories. — The  splitting  and  sorting  of  rattan  is  a 
very  dusty  process  and  extremely  irritating  to  the  respiratory  passages. 
There  is  more  or  less  danger  from  exposure  to  the  fumes  of  sulphur,  quick 
lime  and  chlorine  employed  for  bleaching  the  rattan,  and  likewise  from 
hydrofluoric  acid,  which  is  used  not  only  for  bleaching  purposes,  but  also  for 
the  extraction  of  its  silicates.     (See  also  wood  stains  and  polishes.) 

Whip  and  walking  stick  makers  employ  a  variety  of  material  such  as 
rattan,  wood,  rawhide,  glue,  cotton  thread,   aniline    dyes,  varnishes,  etc. 


THE    LUMBER    INDUSTRY  677 

There  is  always  considerable  production  of  dust  in  the  splitting  and  turning 
of  rattan  and  wood.  Other  injurious  factors  are  bad  working  conditions, 
the  employment  of  chrome  and  other  toxic  stains,  which  together  with  impure 
varnishes  and  polishing  materials  not  infrequently  cause  inflammatory  and 
even  suppurative  inflammation  of  the  hands.  Neisser^*  also  reports  cases  of 
suppurative  skin  affections  in  persons  employed  in  the  curving  of  walking- 
stick  handles,  which  had  been  treated  with  a  solution  of  acetate  of  iron, 
although  the  older  employees  appeared  to  be  exempt  from  such  effects. 

Furniture  Repair  Shops. — The  work  is  generally  carried  on  in  insanitary 
shops,  and  the  persons  engaged  in  renovating  old  furniture  and  upholstery 
are  exposed  to  the  inhalation  of  dust  of  a  mixed  character  possibly  containing 
disease  germs.     (See  also  Upholstery,  page  577.) 

Miscellaneous  Wood  Workers. — In  the  tub  and  pail  industry  the  em- 
ployees, many  of  whom  are  youthful  wage  earners,  are  exposed  to  the  inhala- 
tion of  line  wood  and  sandpaper  dust.  In  the  cutting,  trimming,  turning  and 
polishing  of  sJwe  lasts  larg'e  amounts  of  dust  are  evolved  and  inhaled. 

Moulding  and  Picture-frame  Makers. — In  this  branch  of  industry,  the 
various  processes  are  dusty  and  often  carried  on  without  adequate  ventila- 
tion, while  in  the  bronzing  and  gilding  department  there  is  danger  from  the 
inhalation  of  bronze,  wood  alcohol  and  amyl  acetate  and  so-called  "banana 
oil.''     Leadless  paints  are  almost  e.xclusively  used  for  picture  mouldings. 

Coopers,  like  wood  turners,  have  a  high  mortality  rate  from  consumption 
and  diseases  of  the  respiratory  system,  in  which  the  inhalation  of  hard  wood 
dust  probably  plays  an  important  role.  There  is  also  exposure  to  metal  dust, 
blacksmithing,  sand  blasting  and  painting.  The  men  engaged  in  shellacing 
the  interior  of  casks  are  exposed  to  the  toxic  effects  of  the  wood  alcohol.  (See 
Breweries,  page  694.) 

Preventive  Measures. — Since  dust  inhalation  and  accidents  constitute 
the  most  important  risks,  it  is  evident  that  all  machines  should  be  properly 
guarded  and  mechanical  means  be  provided  for  the  removal  of  dust;  for  the 
latter  purpose,  hoppers,  suction  pipes  and  blowers  have  proved  quite  efficient 
especially  in  connection  with  turning  and  sanding  machines.  Some  of  the 
workmen  claim  that  the  exhaust  flues  cause  disagreeable  drafts  and  rheu- 
matism of  the  finger  joints,  but  this  is  a  minor  objection  and  could  be  pre- 
vented by  wearing  suitable  gloves.  It  is  also  evident  that  persons  handling 
toxic  woods,  and  stains  and  polishes  should  protect  their  hands  and  resort 
to  frequent  ablutions.  All  processes  should  be  carried  on  in  well-ventilated 
rooms,  and  the  vessels  containing  wood  alcohol  should  be  kept  closed  until 
used. 

Robinson  and  Wilson'^  examined  230  persons  emplojed  in  the  carriage  and  wagon 
industry  in  Cincinnati  and  found  only  one  case  of  tuberculosis.  This  is  attributable  to 
79.6  per  cent,  of  the  workers  being  over  25  years  of  age  and  42.6  per  cent,  over  35.  The 
blowers  attached  to  the  dust  producing  machines  (belt-sanding)  removed  a  large  part  of 
the  dust;  steady  work  and  fair  wages  also  plaj-ed  a  role. 

But  a  small  percentage  of  metal  grinding  is  done  in  carriage  factories.     Wirnishing 


678        ETIOLOGY    AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

usually  has  an  injurious  effect  upon  health,  however,  yet  no  sickness  due  to  the  process 
was  found. 

Among  270  employees  engaged  in  the  manufacture oi  furnilure,  only  three  cases  or  i.i  per 
cent,  were  tuberculous.  Much  of  the  work,  i.e.  sawing,  planing,  turning  and  belt-sanding 
is  dusty,  but  powerful  blowers  eliminate  this  hazard  to  a  great  extent;  58.1  per  cent,  of 
the  employees  were  over  35  years  of  age.  The  sanitary  condition  (toilets,  wash  rooms, 
and  general  cleanliness)  was  fair  in  three  and  dirty  in  one  of  the  factories. 

Among  60  motdding  and  picture  frame  workers  no  cases  of  tuberculosis  were  found,  al- 
though four  were  classed  as  much  below  the  normal  standard  of  health.  Some  of  the  men 
engaged  in  bronzing  were  pale  and  complained  of  headaches.  The  fumes  of  amj4  acetate 
were  very  noticeable  in  spite  of  the  employment  of  powerful  exhausts. 

Among  664  employees  (94  females)  engaged  in  the  manufacture  of  pianos,  seven  cases  of 
tuberculosis,  or  slightly  more  than  i  per  cent,  of  those  examined,  were  found.  A  powerful 
blower  system  carried  away  all  dust  produced  by  the  machines.  The  factories  were  pro- 
vided with  good  toilet  facilities,  wash  room,  sanitary  drinking  fountains,  lunch  rooms,  etc. 
Two  of  the  active  cases  of  tuberculosis  were  employed  in  the  varnishing  department  and 
exposed  to  the  fumes  of  naphtha  and  dust  produced  in  sand  papering,  but  both  were  also 
addicted  to  the  use  of  alcohol.  The  reporters  do  not  consider  the  occupation  hazardous 
as  regards  tuberculosis. 

Among  273  workers  engaged  in  cooperage  and  the  manufacture  of  bungs  and  cigar  bo.xes, 
seven  cases  or  2.56  per  cent,  of  those  examined  were  tuberculous.  The  blowers  attached  to 
dust  producing  machines  were  not  always  successful  in  removing  all  of  the  dust.  The  in- 
vestigators point  out  other  unfavorable  conditions,  such  as  temperature,  humidity,  alcohol- 
ism, dissipation,  bad  housing  and  family  histories,  as  possible  predisposing  factors.  Only 
one  case,  a  cooper,  seemed  to  be  due  more  to  occupation  and  bad  working  conditions,  than 
to  any  other  one  thing,  although  even  in  this  case  dissipation  was  also  present. 

REFERENCES 

'  Sternberg,  Max. — Weyl's  Handbuch  der  Arbeiterkrankheiten,  1908,  page  435. 
^  Sommerfeld. — Handbuch  der  Gewerbekrankheiten,.  Berlin,  1908. 

*  Roth. — Gewerbehygiene,  Leipzig,  1907. 

*  Oliver's  Dangerous  Trades,  1902,  page  791. 

*  Neisser. — Internat.  Ubersicht  iiber  Gewerbehygiene,  Berlin,  1907,  page  115. 

*  Nestler. — Prometheus,  Berlin,  1913. 
^  Nestler. — Prometheus,  Berlin,  1913. 

*  Sternberg. — Weyl's  Handbuch  d.  Arbeiterkrankheit.,  1908,  page  433. 

*  Neisser. — Internat.  Ubersicht  iiber  Gewerbehygiene,  1907,  pages  79,  80. 
^^  Oliver. — Diseases  of  Occupation,  London,  1908,  page  258. 

"  Journal  A.  M.  A.,  August  16,  1913,  page  502. 

i^^Sternberg,  Max. — Weyl's  Handbuch  d.  Arbeiterkrankh.,  1908,  page  432. 

I'Ibid.,  433. 

'*  Neisser. — Internat.  Ubersicht,    Berlin,  1907,  page  loi. 

»*  Robinson,  D.  E.,  and  Wilson,  J.  G.— U.  S.  Public  Health  Bulletin  No.  73,  March,  1916. 


CHAPTER  XIV 

OCCUPATIONS  INVOLVING  EXPOSURE  TO  THE  INHALATION  OF 
ORGANIC  GASES,  ETC. 

BY  GEORGE  M.  KOBER,  M.  D.,  Washington,  D.  C. 

Flaying  and  Bone  Yards.     Rendering  Plants.     Manufacture  of  Tallow.     Soap  Industry. 
Glue  Makers.     Basic  or  Thomas  Slag.     Artificial  Manure.     Preventive  Measures. 

Occupations  Involving  the  Inhalation  of  Organic  Gases,  Etc. — Whether 
the  effluvia  from  sewers,  stables,  stock  yards,  rendering  establishments,  glue, 
candle  and  soap  factories,  hide  depots,  fertilizer  plants,  etc.,-  are  injurious  to 
health  remains  an  open  question.  Some  authors  insist  that  the  olfactory 
organs  are  alone  offended  and  point  to  statistics  which  indicate  that  the 
duration  of  life  of  such  employees  is  above  the  average,  quite  forgetful  of 
the  fact  that  weaklings  rarely  engage  in  such  occupations.  It  is  reasonable 
to  assume  that  the  effluvia,  consisting  as  they  do  of  ammonia,  hydrogen  and 
ammonium  sulphide,  are  fully  as  injurious  as  sewer  air,  which,  judging  from 
animal  experimentation,  appears  to  increase  the  susceptibility  to  infectious 
diseases  by  diminishing  the  power  of  resistance. 

In  privy  pits  and  sewers  the  danger  is  intensified  by  an  excess  of  carbonic 
acid  and  corresponding  deficiency  of  oxygen  in  the  air.  Special  precautions 
should  be  taken  to  exhaust  the  foul  air  before  sewer  employees  or  scavengers 
are  allowed  to  descend.  The  general  effects  of  foul  odors  upon  those  un- 
accustomed to  do  work  in  the  so-called  "offensive  trades"  are  nausea,  vomit- 
ing, headache,  loss  of  appetite,  diarrhea,  general  depression,  and  weakness. 
(See  also  Sulphureted  Hydrogen  in  the  list  of  Industrial  Poisons.) 

Flajdng  and  Bone  Yards. — Every  community  provides  for  the  collection 
and  disposal  of  dead  animals,  which  is  usually  done  by  contract.  The  ani- 
mals are  taken  to  some  establishment  beyond  the  residential  limits,  flayed  and 
worked  up,  so  as  to  utilize  the  skin,  hair,  fats,  bones,  horns,  etc.  After  the 
animal  has  been  skinned  and  the  mane,  tail,  hoofs,  and  horns  removed,  the 
carcasses  are  cooked  in  a  boiler  for  the  recovery  of  fat  and  bones  and  the 
fleshy  residue  is  used  for  the  manufacture  of  artiticial  manure.  Apart  from 
exposure  to  extremely  offensive  odors  there  is  more  or  less  danger  of  the  trans- 
mission of  infectious  diseases  communicable  from  animals  to  man,  such  as 
anthrax,  glanders,  tetanus,  tuberculosis,  and  hence  all  such  work  should  be 
done  under  strict  sanitary  control.  Moreover,  during  the  fly  season  there  is 
distinct  danger  from  septic  infection,  by  biting  flies,  in  all  occupations  in- 
volving the  handling  of  decomposing  animal  matter,  and  every  effort  should 
be  made  to  abate  the  fly  nuisance  and  protect  the  workers  by  suitable  screens. 

679 


68o        ETIOLOGY   AND   PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

Rendering  Plants. — In  some  establishments  the  refuse  from  dead  ani- 
mals and  garbage,  such  as  fat,  meat  trimmings,  bones,  etc.,  is  treated  with 
benzine,  carbon  disulphide,  or  by  heat  for  the  extraction  of  fats.  The  prod- 
ucts are  oils,  grease  and  tankage.  When  heated  in  tanks  the  fat  separates  and 
is  drawn  oflf  into  barrels  and  sold  for  the  manufacture  of  soap,  wagon  grease, 
etc.  The  tank  residue  is  subjected  to  pressure  and  the  meat  scraps  are 
converted  into  feed  for  poultry,  or  utilized  for  the  manufacture  of  artificial 
manure.  The  bones  are  either  cleaned  and  dried  and  sold  for  the  manu- 
facture of  buttons,  etc.,  or  are  ground  up  and  converted  into  fertilizers. 
The  tanks  are  usually  provided  with  ventilating  pipes  which  carry  the  odors 
and  gases  to  the  furnaces,  where  they  pass  through  the  fire  and  are  de- 
stroyed. In  spite  of  this  provision  there  is  much  reason  for  assuming  that 
the  evolution  of  volatile  fatty  acids  and  acrolein  are  responsible  for  the 
undue  prevalence  of  catarrhal  affections  of  the  eyes,  air  passages  and  of  the 
stomach. 

The  Manufacture  of  TaUow. — Tallow  is  a  mixture  of  olein,  stearin  and 
palmitin,  chiefly  the  first  two,  and  melts  at  a  temperature  of  between  ioo° 
and  i20°F.  The  better  grades  are  obtained  by  rendering  beef  or  mutton 
fats,  but  inferior  qualities  used  for  soaps  are  secured  from  the  refuse  fats  al- 
ready referred  to,  and  even  from  whale  or  fish  oil.  Dr.  C.  F.  W.  Doehring^ 
has  described  in  detail  the  methods  employed  in  the  manufacture  of  tallow: 
"There  are  a  series  of  cylinders  of  1200  to  1500  gal.  capacity  employed  in 
rendering  the  fats  when  the  tissues  are  not  required  in  a  condition  otherwise 
than  is  suitable  for  manure.  The  cylinders,  are  filled  above  a  false  bottom 
with  the  crude  fat  and  steam  is  admitted  by  a  foot  valve  and  perforated  pipe 

at  50  or  even  100  lb.  pressure After  10  to  15  hours  the  steam 

is  cut  off  and  the  cock  and  safety  valves  are  opened,  and  after  settling,  the 
layer  of  tallow  is  drawn  off  through  a  series  of  cocks.  The  cover  of  a  dis- 
charge hole  in  the  bottom  of  the  cylinder  is  then  raised  by  a  rod,  and  the 
residue  falls  into  the  tub  beneath.  To  remove  the  last  traces  of  tissue  it 
is  necessary  for  the  tallow  to  be  washed,  melted  and  strained.  This  process 
extracts  more  tallow  from  the  fat  than  any  other.  Sometimes  the  fat  is  ren- 
dered at  the  atmospheric  pressure  by  boiling  a  mixture  of  the  fat  with  one- 
fourth  of  its  bulk  of  water,  containing  2-3  per  cent,  of  sulphuric  acid." 

Several  processes  are  employed  for  bleaching  and  purifying  tallow. 
Apart  from  subsidence,  mechanical  filtration  and  aeration,  various  chemicals 
have  been  used,  such  as  potassium  carbonate,  or  potassium  permanganate, 
or  bleaching  powder  in  the  proportion  of  i  per  cent,  or  potassium  chlorate 
in  the  proportion  of  0.03  per  cent,  with  the  addition  of  hydrochloric  and 
sulphuric  acid.  In  some  establishments,  the  tallow  is  purified  by  heating 
with  soda  a^nd  salt  solution  and  boihng  the  unsaponified  portion  with  a  23^^ 
to  3  per  cent,  solution  of  alum.  It  is  very  evident  that  the  workers  are  ex- 
posed not  only  to  very  offensive  odors  but  also  to  a  number  of  toxic  fumes. 
The  Soap  Industry. — During  the  last  census  about  13,000  persons  were 


EXPOSURE    TO    THE    IXHALATIOX    OF    ORGANIC    GASES,    ETC.         68 1 

employed  in  the  United  States  in  soap  making.  The  manufacture  of  soap 
and  candles  is  usually  carried  on  in  the  same  establishment,  and  bcause  of 
the  offensive  odors  evolved  the  occupation  has  been  considered  unwhole- 
some. The  inspectors  of  the  State  Board  of  Health  of  Massachusetts  do 
not  share  this  opinion  and  report  that  the  employees  as  a  class  appear  to 
be  in  good  health.  The  Leipsic  statistics  for  female  tallow  and  soap  workers 
show  1085  days  of  sickness  per  annum  per  100  members  and  a  mortality 
hazard  of  1.14  per  cent. 

In  the  manufacture  of  soap,  animal  fats  or  oils,  such  as  olive,  cocoanut 
or  palm,  containing  the  fatty  substances  olein,  palmitin  and  stearin,  are  heated 
with  either  caustic  potash  or  soda.  This  converts  the  fatty  substances  into 
oleic,  palmitic  and  stearic  acids,  which  combine  with  the  alkaUne  base  and 
form  oleate,  palmitate  and  stearate  of  potassium  or  sodium,  while  glycerine 
is  set  free  and  saved  as  a  by-product.  Hard  soap  results  when  soda  is  used 
as  a  base,  and  soft  soap  is  the  product  when  potash  is  employed. 

In  addition  to  the  materials  mentioned  various  coloring  matters  are  em- 
ployed. For  example,  the  marbled  or  mottled  appearance  of  castile  soap 
is  produced  by  the  addition  of  ferruginous  matter.  Toilet  soaps  are  fre- 
quently colored  ■^'ith  harmless  aniline  dyestuffs  and  scented  with  essential 
oils  and  artificial  perfumes  which  may  cause  headache.  The  most  dangerous 
agent  employed  is  nitrobenzol,  which  not  infrequently  produces  malaise, 
headache,  giddiness,  nausea  and  other  symptoms  of  nitrobenzol  intoxication. 
Dr.  Griin^  suggests  that  some  of  the  chronic  affections  of  the  kidney  and 
bladder  may  be  caused  by  the  perfumes  and  chemical  dyestuffs  employed. 
The  manufacture  of  medicated  soaps  containing  sulphur,  tar,  etc.,  like  toilet 
soaps,  involves  more  complicated  processes. 

Apart  from  exposure  to  volatile  fatty  acids,  acrolein  vapors  and  soap 
dusts,  the  employees  may  sustain  injuries  from  machinery,  burns  from 
caustic  alkalies,  and  eczema  from  exposure  to  acids.  Wounds  and  abrasions 
are  not  infrequently  followed  by  erysipeloid  infections.  It  is  generally  be- 
lieved that  exposure  to  the  vapors  of  fatty  acids  is  productive  of  catarrhal 
affections  of  the  upper  air  passages,  and  Griin  accounts  for  the  undue  pre- 
valence of  acute  and  chronic  gastric  catarrh  among  soap  makers  by  the  fact 
that  they  swallow  a  sufficient  amount  of  alkaline  vapors  to  neutralize  the 
hydrochloric  acid  of  the  gastric  juice,  and  that  fatty  acids  ingested  also  act 
as  chemical  irritants.  All  of  these  hazards  can  be  reduced  to  a  minimum 
by  hoods  and  exhaust  ventilation. 

Glue  Makers. — Glue  is  usually  an  impure  gelatine  derived  from  boiling 
animal  substances  such  as  fleshings,  scraps  of  hide,  hoofs,  horns,  etc.  The 
material  is  first  washed  and  then  soaked  for  a  few  days  in  lime  water  in 
suitable  tanks  for  the  purpose  of  loosening  the  hair.  This  is  removed  and 
dried  by  steam  heat  and  sold  for  plastering  purposes.  The  residue  is  washed 
for  the  removal  of  lime  and  exposed  to  the  action  of  steam  in  suitable  tubs. 
The  liquid  glue  is  drawn  off  from  below  and  allowed  to  solidify  in  pans  to  a 


682        ETIOLOGY   AND    PROPHYL.\XIS    OF    OCCUPATIONAL   DISEASES 

hard  jelly,  which  is  then  cut  into  slices,  transferred  to  screens  and  thoroughly 
dried.  Glue  is  generally  sold  in  thin,  hard  and  brittle  cakes,  although  some- 
times it  is  ground  up  in  the  factory.  This  involves  more  or  less  dust  pro- 
duction. The  residue  in  the  tubs  is  further  treated  for  the  extraction  of 
fatty  matter. 

The  glue  manufactured  from  by-products  of  the  fish-preserving  industry 
is  usually  evaporated  to  the  required  consistency  and  sold  in  a  liquid  form. 
In  the  manufacture  of  so-called  Cologne  glue,  which  is  a  pale  strong  glue, 
considerable  chloride  of  lime  is  used  for  bleaching  purposes. 

The  manufacture  of  gelatine  for  dietetic  purposes  is  carried  on  along  the 
same  hnes,  except  that  none  but  pure  and  wholesome  stock  is  used,  and  the 
entire  process  is  conducted  with  special  regard  for  cleanHness. 

Preventive  Measures. — While  it  is  true  that  the  workers  in  these  so- 
called  offensive  trades  generally  appear  to  be  in  good  health,  it  should  be 
remembered  that,  as  a  rule,  only  men  of  rugged  physique  engage  in  these 
disagreeable  occupations.  As  already  indicated  the  inhalation  of  organic 
gases  and  of  volatile  fatty  acids  and  acrolein  is  not  free  from  danger  and 
should  be  guarded  against  by  copious  ventilation  and  exhaust  flues.  Personal 
cleanliness  is  likewise  important  and  all  wounds  and  abrasions  should  be 
treated  with  antiseptics. 

Basic  or  Thomas  Slag. — In  the  manufacture  of  steel  by  the  Gilchrist- 
Thomas  method  a  slag  is  formed,  which  contains  from  10-25  per  cent,  of 
soluble  phosphoric  acid  and  naturally  led  to  its  utilization  as  a  fertilizing 
agent.  This  involves  crushing  and  grinding  operations  of  a  very  dusty 
character,  and  hence  diseases  of  the  respiratory  organs  are  quite  common. 
In  some  of  the  workers  ulcerations  of  the  mucous  membranes  have  been 
observed  and  the  undue  prevalence  of  pneumonia  among  this  class  may 
reasonably  be  attributed  to  the  fact  that  the  pathological  changes,  produced 
by  the  corrosive  action  of  quicklime  present  in  the  dust,  favor  infection  with 
the  pneumococcus. 

Foreign  statistics  show  an  undue  morbidity  rate  especially  from  pneu- 
monia, conjunctivitis,  and  eczema.  In  recent  years  a  process  of  granulating 
basic  slag,  under  the  influence  of  a  stream  of  water,  has  been  introduced, 
which,  while  it  obviates  the  dangers  of  dust  production,  is  attended  with  the 
evolution  of  sulphuretted  hydrogen.  This  should  be  guarded  against  by 
copious  ventilation.  It  should  be  stated  that  granulated  slag,  apart  from 
being  used  as  a  fertiUzer,  is  also  utilized  in  the  manufacture  of  cement, 
artificial  stone,  etc. 

Artificial  manure  is  also  made  from  various  materials  rich  in  phosphate 
of  lime.  For  this  purpose  phosphorites,  cuproHtes,  bone  dust,  guano,  etc., 
are  employed.  The  grinding  of  the  raw  material  involves  exposure  to  caustic 
dust  and  should  be  carried  on  automatically  in  enclosed  ball  mills.  The 
material  is  then  mixed  with  sulphuric  acid  which  renders  the  insoluble  phos- 
phates soluble.      During  this  process,   hydrofluoric,    silico-fluoric,  hydro- 


EXPOSURE    TO    THE    INHALATION   OF   ORGANIC    GASES,    ETC.         683 

chloric  and  carbonic  acid  vapors  are  evolved  and  also  sulphur  dioxide  and 
sulphuretted  hydrogen.  These  gases  should  be  promptly  removed  by  acid 
proof  exhaust  fans  and  condensed.  Cases  of  poisoning  from  nitrous  fumes 
may  occur  in  the  manufacture  of  fertilizers  in  mixing  Chili  nitre  with  strong 
acid  superphosphates.  When  ground  bones  are  used,  the  fats  are  first 
extracted  by  means  of  benzine,  which  contributes  an  additional  element  of 
dariger. 

My  former  student.  Dr.  C.  F.  W.  Doehring,^  has  described  the  conditions 
observed  in  some  of  the  fertilizer  plants,  and  emphasized  the  danger  from 
biting  flies,  the  clouds  of  dust  and  exposure  to  acid  fumes  in  some  of  the  super- 
phosphate factories. 

In  addition  to  the  materials  already  referred  to,  the  following  are  sources 
for  artificial  manure.  The  deposits  of  native  guano  consist  of  the  excrement 
and  carcasses  of  sea  fowl,  but  many  of  these  deposits  are  now  exhausted  and 
artificial  guano  is  made  from  the  tank  refuse  of  dead  animals,  garbage, 
carcasses  of  whale  and  fish,  after  extraction  of  the  fats.  Other  sources  for 
artificial  manure  are  seaweed,  soot,  damaged  oil  cakes,  nitrate  of  soda, 
sulphate  of  ammonia,  the  latter  chiefly  a  by-product  of  gas  works,  also  dried 
blood,  refuse  of  hoof,  horns,  leather  and  wool. 

In  examining  581  employers  in  different  soap  factories  in  Cincinnati, 
Robinson  and  Wilson^  found  10  cases  or  1.7  per  cent,  of  tuberculosis.  The 
manufacture  of  soap  powder  is  attended  with  the  production  of  much  dust 
containing  soda  ash,  which  in  addition  to  the  blower  system  frequently  com- 
pels the  employment  of  respirators.  Apart  from  this,  long  working  hours, 
"speeding  up"  and  low  wages  are  referred  to  as  deleterious  influences. 

Among  the  66  employees  of  a  fertilizer  plant,  only  i  case  of  tuberculosis 
was  found,  and  he  was  a  colored  coal  passer,  who  had  12  hours  of  work  a  day 
and  sometimes  slept  in  the  fire  room.  The  low  incidence  is  attributed  by 
the  investigators  to  the  fact  that  the  majority  of  the  employees  belonged  to 
a  selected  class  and  71.2  per  cent,  were  over  35  years  of  age,  and  hence 
beyond  the  most  dangerous  age  period  for  tubreculosis. 

REFERENCES 

1  Doehring,  C.  F    W. — Factory  Sanitation  and  Labor  Protection.     Bull.  Bureau  of  Labor 

No.  44,  January,  1903. 

2  Griin,  Heinrich.— Weyl's  Handbuch  d.  Arbeiterkrankh.,  Jena,  1908. 

3  Robinson,  D.  E.,  and  Wilson,  J.  G.— U.  S.  Public  Health  Bulletin  No.  73.  March,  1916. 


CHAPTER  XV 
THE  INDUSTRY  OF  FOOD  STUFFS,  ETC. 

BY  GEORGE  M.  KOBER.  M.  D.,  Washington.  D.  C. 

Grain  and  ISIilling  Industry.  Flour  Milling.  Bakers,  Confectioners  and  Pastry  Cooks. 
Manufacture  of  Glucose  and  Starch.  The  Sugar  Industry.  The  Fish  Industry. 
The  Slaughtering  and  Meat  Packing  Industry.  The  Manufacture  of  Oleomargarine. 
Lard  ISIaking.  Dairy  Industry.  The  Canning  and  Preserving  Industry.  Brewer- 
ies, Distilleries,  etc.  Manufacture  of  Vinegar.  Manufacture  of  Carbonated  Waters. 
Artificial  Ice.  Cold  Storage.  Chloride  of  Sodium.  The  Tobacco  Industry.  Tobacco 
Testers.  Tea  Testing.  Hotel,  Restaurant,  and  Saloon-Keepers.  Domestic  and 
Personal  Service.     Barbers  and  Hair  Dressers. 

The  Grain  and  Milling  Industry. — Grain  Threshing. — It  is  well  known 
that  even  the  modern  threshing  process  has  not  materially  diminished  the 
liability  to  dust  inhalation.  Fortunately,  the  exposure  to  this  mixture  of 
dust  of  an  organic  and  inorganic  origin  is  usually  for  a  short  duration,  but 
even  as  it  is,  we  not  infrequently  observe  acute  bronchial  catarrh  and  in- 
flammatory conditions  of  the  eyes,  nose  and  throat  and  quite  commonly  also 
intense  itching  of  the  skin. 

During  the  season  of  1914  numerous  fires  occurred  in  the  State  of  Wash- 
ington in  connection  with  the  threshing  operations,  especially  in  the  thresh- 
ing separator.  These  fires  were  of  an  explosive  character  and  numerous 
persons  were  seriously  injured,  usually  by  fire,  and  in  a  few  cases,  by  the 
force  of  the  explosion. 

Investigation  rendered  it  reasonably  certain  that  the  cause  of  the  fire 
was  an  unusually  large  amount  of  stinking  smut  (tilletia  tritici)  in  the  wheat 
which  contains  from  4-5  per  cent,  of  inflammable  oil.  An  exceedingly  dry 
season  increased  the  amount  of  organic  dust  from  broken  grain  and  straw, 
and  also  increased  the  combustibihty  of  both  smut  and  dust,  and  the  amount 
of  static  electricity.^ 

While  the  source  of  ignition  has  not  been  positively  proved,  it  would 
appear  that  static  electric  sparks,  which  are  generally  present  in  the  cylinders 
of  the  separator,  are  the  cause  in  the  majority  of  instances,  and  hence  it  is 
urged  that  the  cyHnders  of  the  separator  be  grounded  by  means  of  an  elec- 
tric brush  connected  to  the  ground  by  wire,  attached  to  an  iron  peg  driven  a 
foot  or  two  into  the  ground. 

Workers  in  Grain  Elevators. — The  amount  of  dust  is  very  much  less  in 
handling  grain  after  it  leaves  the  threshing  machines.  More  or  less  dust,  is, 
however,  gathered  in  transport  and  is  also  produced  by  the  attrition  of  the 
individual  grains  during  shipment.  The  dust  from  rye  and  wheat  grain  on 
account  of  the  sharp  particles  of  the  husk  is  more  irritating  than  that  caused 


THE  INDUSTRY  OF  FOOD  STUFFS,  ETC.  685 

by  oats,  but  the  latter  give  off  a  larger  volume.  The  dust  from  corn  usually 
contains  large  quantities  of  mineral  matter  and  fragments  of  husks.  The 
construction  and  equipment  of  modern  grain  elevators  reduce  exposure  to 
dust  to  a  minimum;  nevertheless  the  men  engaged  in  shovelling  the  grain 
toward  the  mouth  of  the  elevators  and  those  who  work  in  the  bins,  turning 
over  corn  or  grain  to  prevent  heating,  are  exposed  to  clouds  of  dust.  Most 
of  this  work  is  done  by  casual  labor  and  the  injurious  effects  would  be  more 
pronounced  if  the  employment  were  constant  instead  of  seasonal.  No 
extended  statistical  material  is  available  to  determine  conclusively  the  un- 
heal thful  character  of  this  occupation.  Hoffman^  found  that  of  24  deaths 
from  all  causes  among  grain  handlers  and  elevator  men  5,  or  20.8  per  cent, 
died  from  consumption,  as  compared  with  14.8  per  cent,  in  the  general  male 
population  in  1906. 

Preventive  Measures. — While  much  has  been  done  to  reduce  the  dangers 
from  dust  inhalation  by  automatic  processes,  no  effort  should  be  spared  to 
render  the  devices  for  the  arrest  and  removal  of  dust  more  effective.  In  the 
meantime  the  workers  so  exposed  should  protect  their  nostrils  and  mouths 
by  handkerchiefs  as  the  ordinary  respirators  soon  become  clogged  and 
embarrass  respiration. 

Flour  Milling. — In  spite  of  the  tremendous  growth  of  commercial  mills, 
there  are  still  a  large  number  of  custom  mills,  where  the  facilities  for  the 
arrest  and  removal  of  dust  are  not  nearly  so  good  as  in  the  large  patent 
rolling  process  establishments.  But  even  in  modern  mills  where  the  cleaning, 
grinding  and  bolting  is  done  in  inclosed  machinery,  there  is  always  more  or 
less  exposure  to  grain  and  flour  dust,  while  the  men  engaged  in  dressing 
the  buhrstones  which  are  still  in  use  in  some  of  the  custom  mills  are  also  ex- 
posed to  mineral  and  metallic  dust.  If  statistics  were  available  it  would 
probably  be  found  that  these  men,  and  those  connected  with  the  cleaning 
of  the  grain  preliminary  to  the  milUng,  furnish  the  highest  percentage  from 
diseases  of  the  respiratory  system;  the  flour  and  bran  packers,  counters, 
sweepers  and  warehouse  men  would  probably  come  next  in  frequency.  The 
inhalation  of  flour  dust,  in  spite  of  the  smooth  and  less  irritating  character 
of  the  individual  particles  comprising  it  cannot  fail  to  prove  injurious  to 
the  respiratory  organs.  Indeed  there  is  much  reason  for  assuming  that  the 
lodgment  of  flour  dust  in  the  minute  ramification  of  the  bronchial  tubes  and 
air  vesicles  apart  from  clogging  up  the  air  passages  and  acting  as  an  irritant, 
may  result  in  collapse  of  a  small  area  of  the  lung  (atelectasis)  or  in  a  dilatation 
of  the  vesicles  and  an  abnormal  collection  of  air  in  the  lung  tissue,  technically 
called  emphysema,  and  popularly  known  as  "miller's  asthma."  Other  dis- 
eases of  the  lungs  are  even  more  common.  According  to  Hirt,  20.3  per  cent, 
of  all  the  diseases  affecting  millers  are  pneumonia;  9.3  per  cent,  bronchial 
catarrh;  10.9  per  cent,  consumption;  and  1.9  per  cent,  emphysema  a  total 
of  42.4  per  cent,  from  diseases  of  the  respiratory  passages.  These  rales  are 
about  II  per  cent,  in  excess  of  the  statistics  furnished  by  Hoffman-  who  found 


686        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

that  of  256  deaths  in  millers,  in  this  country,  31.6  per  cent,  were  caused  by 
diseases  of  the  lungs,  inclusive  of  40  deaths,  or  15.6  per  cent.,  from  con- 
sumption and  29  deaths  or  11. 4  per  cent,  from  pneumonia.  The  statistics 
of  Hirt  cover  an  older  period  and  the  difference  is  largely  due  to  the  less 
harmful  processes  employed  in  modern  mills.  But  the  New  York  State  Bu- 
reau of  Labor  reports  for  1906  a  very  high  death  rate  from  pneumonia  in 

millers.' 

Cases  of  chronic  indigestion  are  not  uncommon  among  millers,  which 
the  writer  feels  disposed  to  attribute  to  the  swallowing  of  flour  dust.  Since 
uncooked  starch  is  not  readily  digested,  it  is  very  liable  to  undergo  fermenta- 
tion and  thus  injure  the  gastric  mucosa.  Millers  occasionally  suffer  from 
inflammatory  conditions  of  the  skin,  impacted  ear  wax  and  partial  deafness. 
Other  sources  of  danger  in  connection  with  flour  milling  are  exposure  to 
sulphurous  acid  fumes  when  used  for  bleaching  purposes,  accidents  from 
moving  belts  and  machinery,  fire  and  explosions. 

According  to  the  preliminary  report  of  the  miller's  Committee  of  Buffalo^ 
in  13  explosions  investigated  in  recent  years  in  the  milling  industry  in  this 
country,  78  men  were  killed  and  119  injured  and  the  total  damage  to  the 
property  exceeded  $2,000,000.  Dr.  H.  H.  Brown's  laboratory  studies  have 
shown  that  grain  dusts,  especially  from  oats  and  yellow  corn,  are  even  more 
inflammable  than  standard  coal  dust  and  develop  higher  pressure  on  ex- 
plosion. Apart  from  the  generally  recognized  source  of  ignition  such  as  the 
use  of  open  lights  or  naked  flames,  the  committee  mentions  electric  sparks 
from  motors,  fuses,  switches  and  Hghting  systems,  static  electricity  produced 
by  friction  of  pulleys  and  belts,  and  the  introduction  of  foreign  material  in 
grinding  machines. 

The  Committee  found  the  latter  in  recent  years  a  very  frequent  cause 
and  expresses  the  hope  that  some  system  may  be  devised  by  which  the 
foreign  material  might  be  removed  before  it  reaches  the  mill. 

Preventive  Measures. — Since  cork  dust  explosions  are  often  caused  by 
particles  of  iron  producing  sparks  in  passing  through  the  mill,  a  like  cause 
may  be  surmised  in  this  instance,  and  Doehring's  recommendation  that  the 
cork  be  passed  through  a  magnetic  separator  before  being  placed  in  the 
comminuting  machine  would  be  equally  applicable  for  the  prevention  of 
explosions  in  the  flour  industry.  The  recommendations  of  the  Committee 
may  be  summarized  as  follows:  Complete  lighting  systems,  portable  electric 
lamps  instead  of  lanterns  and  naked  lights,  the  inclosing  of  the  electric  light 
bulbs  in  strong  wire  guards;  the  possible  use  of  vapor  proof  globes,  and  the 
locating  of  all  fuses,  switches,  starting  boxes,  motors,  etc.,  at  points  where 
no  dust  is  present.  The  receiving  bins  from  the  grinding  machines  to  be 
as  small  as  compatible  with  the  operations,  as  increased  size  gives  increased 
space  for  dust  clouds  and  therefore  opportunities  for  more  violent  and 
destructive  explosions.  Above  all  else  dust  should  be  prevented  from 
escaping  into  the  air  of  the  workrooms. 


THE    INDUSTRY   OF   FOOD    STUFFS,    ETC.  687 

Bakers,  Confectioners  and  Pastry  Cooks.~The  preceding  remarks 
concerning  the  inhalation  of  flour  dust  apply  equally  to  this  class  of  workers, 
except  that  there  is  a  less  intensive  exposure  and  that  millers  are  also  liable 
to  the  inhalation  of  grain  dust.  At  all  events  Hirt's  German  statistics  are 
somewhat  in  favor  of  bakers,  whose  mortality  rate  from  diseases  of  the 
lungs  was  28.2  per  cent,  against  42.4  per  cent,  in  millers;  their  consumption 
rate  was  7  per  cent,  against  10.9  per  cent,  in  millers,  and  11.6  per  cent,  in 
confectioners  and  the  pneumonia  rate  was  8.4  per  cent,  against  20.3  per  cent, 
in  millers.  Hoffman's^  statistics  based  upon  1357  deaths  among  bakers  in 
the  United  States,  from  all  causes,  are  not  so  favorable  as  they  show  a  death 
rate  of  34  per  cent,  from  diseass  of  the  lungs  and  air  passages,  inclusive  of  a 
consumption  rate  of  20.4  per  cent.,  while  the  confectioners  reveal  a  mortality 
rate  of  39  per  cent,  from  diseases  of  the  lungs  inclusive  of  a  consumption  rate 
of  22.2  and  a  pneumonia  rate  of  13  per  cent.  The  excessive  American  rates 
may  be  due  to  more  unfavorable  environments  of  our  smaller  bakeries,  for 
it  is  very  doubtful  whether  in  any  other  country,  except  perhaps  in 
London  so  many  bakeshops  are  located  in  basements,  wholly  unfit  for 
the  purpose. 

The  excessive  rates  in  confectioners  may  be  due  to  several  factors: 
first,  because  it  is  quite  common  for  delicate  individuals  to  engage  in  this 
work;  second,  certain  operations,  for  example  the  dipping  of  chocolate  candies, 
involve  a  temperature  between  66°  and  68°,  which  in  summer  is 
secured  by  refrigerating  pipes  and  the  exclusion  of  the  outer  air,  with  cor- 
responding pollution  of  the  air  of  the  workshops;  lastly,  confectioners  either 
inhale  or  ingest  more  or  less  pulverized  sugar.  It  is  known  that  lodgment  of 
this  dust  upon  the  teeth  and  gums,  unless  removed  by  frequent  cleaning, 
favors  fermentation  processes  and  decay  of  the  teeth,  and  there  is  much  reason 
for  assuming  that  such  a  condition  may  likewise  favor  the  proliferation  and 
virulence  of  disease  germs,  such  as  the  pneumococcus,  which  is  quite  fre- 
quently found  in  the  buccal  cavity  of  normal  individuals. 

Other  factors  prejudicial  to  the  health  of  bakers  are  exposure  to  heat, 
coal  gas,  impure  air,  long  hours  and  hard  work;  this  is  especially  true  of 
city  bakers  whose  mortality  is  very  much  higher  than  in  towns  and  villages. 
Apart  from  diseases  of  the  respiratory  passages,  anaemia,  probably  caused 
by  chronic  gas  poisoning,  acute  infectious  diseases,  digestive  disorders,  and 
diseases  of  the  heart  are  quite  common. 

Bakers,  and' all  others  engaged  in  handHng  dough,  are  liable  to  suffer 
from  eczema  of  the  hands  and  arms  ("bakers  itch")  and  also  evince  a  pecuHar 
susceptibihty  to  scabies,  pimples  and  boils.  Conjunctivitis  is  likewise  quite 
common  and  youthful  employees  frequently  develop  "in-knee"  "knock- 
knee"  and  "flat-foot." 

Fractures,  burns  and  scalds  were  always  common.  Other  accidents, 
such  as  contusions  and  incised  wounds,  have  increased  with  the  introduction 
of  modern  mixing,  kneading  and  cutting  machines. 


688        ETIOLOGY   AND   PROPHYL.AXIS    OF   OCCUPATIONAL   DISEASES 

Preventive  Measures. — While  Health  Boards  have  been  quite  active 
in  their  efforts  to  secure  better  sanitation  of  bakeries,  it  is  evident  that  more 
should  be  done  in  the  way  of  legal  requirements.  There  is  no  good  reason 
why  bakeshops  located  partly  below  ground  should  be  tolerated,  and  why 
the  manufacture  of  the  "stafif  of  life"  should  not  be  carried  on  under  more 
favorable  sanitary  environments,  as  regards  air-space,  light,  ventilation, 
general  and  personal  cleanliness,  with  benefit  to  the  producer  and  consumer 
alike.  It  is  to  be  hoped  that  machine  labor  will  displace  at  least  the  "  drudg- 
ery" of  the  bakeshop  and  that  day  work  with  reasonable  hours  will  take 
the  place  of  night  work.  Italy  passed  a  law  in  1908  for  the  abolition  of  night 
work  in  bakeries. 

Manufacture  of  Glucose  and  Starch. — During  the  last  census  year  this 
industry  aflforded  employment  to  5827  persons  of  whom  4773  were  wage 
earners.  Starch  is  made  chiefly  from  corn,  although  wheat  and  potatoes 
are  also  used.  There  is  no  statistical  data  upon  which  to  base  conclusions 
as  to  the  injurious  health  factors  in  this  industry.  It  is  evident,  however, 
that  the  work  around  the  steeping  tanks  is  connected  with  exposure  to  damp- 
ness and  inhalation  of  putrefactive  gases,  especially  in  the  alkaline  process," 
in  which  the  corn  is  steeped  in  water  at  a  temperature  of  7o°-i4o°,  from  3-10 
days.  The  handling  of  the  corn  or  wheat,  preliminary  to  maceration,  in- 
volves exposure  to  grain  dust;  while  the  drying  of  the  starch,  which  is  done 
in  rooms  with  a  temperature  between  125°  to  170°,  involves  exposure  to 
starch  dust  and  abrupt  changes  in  temperature,  all  of  which  cannot  fail  to 
affect  adversely  the  health  of  those  exposed.  As  in  the  case  of  flour  mills 
there  is  also  danger  from  explosion  of  dry  starch. 

Glucose  is  made  commercially  by  treating  starch  with  diluted  sulphuric 
acid.  The  resulting  solid  product  is  called  grape  sugar,  and  the  syrup, 
glucose.  In  this  process  the  workmen,  in  addition  to  the  other  injurious 
factors,  are  also  exposed  to  sulphuric  acid  fumes,  and  arsenical  poisoning  of 
the  acid  is  made  from  arsenical  pyrites. 

Preventive  Measures. — Provisions  should  be  made  for  the  removal  of 
dust  and  obnoxious  gases.  The  employees  should  not  be  obliged  to  remain 
in  overheated  rooms  any  longer  than  is  necessary;  and  actual  work  in  storing 
and  removal  of  the  starch  from  the  drying  departments  should  not  be  done 
until  the  temperature  is  below  90°. 

The  Sugar  industry  practically  covers  three  industries,  viz.,  the  manu- 
facture of  "beet  sugar,"  "sugar  and  molasses,"  and  "sugar  refining." 
The  total  number  of  persons  employed  in  the  United  States  in  1909  was  24,047 
14,047,  of  whom  34.9  per  cent,  were  engaged  in  the  beet  sugar  factories,  22.1 
per  cent,  in  the  cane  mills  and  43  per  cent,  in  the  refineries. 

The  work,  like  the  manufacture  of  starch,  involves  exposure  to  dampness, 
excessive  heat,  humidity  and  steam,  especially  during  the  condensation  proc- 
ess where  the  atmosphere  of  the  room  is  generally -above  95°  and  the  relative 
humidity  about  96°,  with  corresponding  dangers  incident  to  abrupt  changes 


THE    INDUSTRY    OF    FOOD    STUFFS,    ETC.  689 

in  temperature.  The  employees  not  infrequently  work  stripped  to  the  waist, 
and,  as  a  result  of  moisture  and  contact  with  the  sticky  substances,  develop 
eczematous  conditions  of  the  skin.  Cases  of  inflammation  of  the  lymphatic 
vessels,  caused,  according  to  M.  Gaillot  by  the  staphylococcus  pyogenes 
aureus  found  in  the  residue  of  molasses,  are  occasionally  observed.  In  his 
opinion  this  organism  may  produce  virulent  toxins  and  fatty  acids  by  the 
conversion  of  saccharine  material  into  lactic,  acetic  and  butyric  acids,  and 
the  soluble  poisons,  as  well  as  the  microorganisms,  may  enter  through  the 
hair  follicles.  A  number  of  the  processes  also  involve  exposure  to  industrial 
poisons,  such  as  ammonia,  sulphurous  fumes,  carbonic  acid,  sulphuretted 
hydrogen,  and  the  inhalation  of  bone  black  dust.  There  is  also  a  slight 
liability  to  phosphorus  poisoning  from  the  bone  black  refuse  of  sugar  mills. 
The  regeneration  of  animal  charcoal  involves  exposure  to  offensive  gases, 
including  the  products  of  putrefaction  and  fermentation.  In  the  beet  sugar 
industry,  especially  when  the  diffusion  method  is  employed,  an  exp'osive 
mixture  probably  containing  carburetted  hydrogen,  has  proved  a  source  of 
danger  to  the  operatives.  The  refuse  waters  from  such  plants  have  been 
regarded  for  some  time  as  a  source  of  stream  pollution  and  are  therefore 
subjected  to  treatment  before  discharge  into  open  water  courses.  The  men 
employed  in  connection  with  the  sedimentation  tanks  are  exposed  to  the 
inhalation  of  sulphuretted  hydrogen  and  other  impure  gases.  The  Leipsic 
statistics  show  a  morbidity  rate  of  1443  days  per  annum  per  100  workers 
in  sugar  refineries. 

Preventive  Measures. — Adequate  provisions  should  be  made  for  ventila- 
tion and  general  cleanliness.  Prof.  Roth^  points  out  that  only  strong  men 
with  an  active  skin  should  be  employed.  Ample  washing  facilities  for  the 
prevention  of  eczema  should  be  available.  The  water-closets  should  be  so 
located  as  not  to  involve  exposure  to  abrupt  changes  in  temperature.  It  is 
gratifying  that,  according  to  Neisser,^  these  recommendations  are  being 
complied  with  in  a  number  of  plants. 

Fish  Industry. — The  occupation  of  fishermen  necessarily  involves  ex- 
posure to  the  inclemency  of  the  weather,  but  it  cannot  be  said  that  the 
occupation  is  dangerous  to  health,  since  it  occupies  the  eighth  rank  in  the 
comparative  mortality  of  22  occupations  tabulated  in  England  and  Wales. 

The  work  of  fish  curing  has  some  special  interest  because  of  the  employ- 
ment of  a  large  number  of  females,  and  also  because  during  the  herring  season 
it  involves  long  and  irregular  working  hours  and  even  night  labor.  Miss 
Mary  M.  Patterson^  in  discussing  the  herring,  cod  and  haddock  curing  in- 
dustry with  special  reference  to  female  labor,  points  out  that  as  a  result  of 
long  hours  and  exposure,  rheumatism,  bronchitis  and  diseases  of  the  lungs 
are  not  uncommon.  Severe  cuts,  slow  healing  and  septic  wounds  are  not 
infrequent.  In  speaking  of  injurious  environments  she  observes,  "the  very 
ground  they  stand  on  is  often  a  menace  to  health,  for,  in  the  absence  of 
proper  paving  and  drainage,  the  earth  becomes  impregnated  with  decaying 

44 


690        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

organic  matter,  which  'smells  to  heaven'  and  creates  a  constantly  foul  at- 
mosphere, not  completely  counteracted  by  the  open-air  surroundings." 

The  hygiene  of  this  industry  has  been  very  much  improved  since  the  es- 
tablishment of  modern  canneries,  and,  while  the  primitive  conditions  still 
prevail  in  the  curing  of  herring  and  cod  fish  in  different  sections,  the  handling 
of  most  of  the  sea  food  is  now  carried  on  under  more  favorable  working 
conditions. 

Preventive  Measures. — Special  attention  should  be  given  to  the  construc- 
tion of  the  buildings;  cement  floors,  wooden  lattice  work  for  the  employees 
to  stand  on,  suitable  tables  so  that  the  water  will  drain  away  from  the 
workers,  rubber  aprons  and  boots,  good  ventilation  for  the  removal  of  bad 
air  or  steam  and  suitable  dressing  and  lunch  rooms  should  be  provided. 
Much  of  the  work  is  now  done  by  machines,  and  the  method  for  the  collection 
and  utilization  of  the  offal  have  been  perfected,  so  as  not  to  constitute  a 
menace  to  public  or  private  health. 

The  Slaughtering  and  Meat-packing  Industry. — The  average  numbet-ol— 
persons  engaged  in  this  industry  during  the  last  census  year  was  108,716; 
of  whom  7413  were  females.  The  total  number  of  animals  slaughtered 
for  food  was  88,358,815;  hogs  represented  60.2  per  cent.,  sheep  and  lamb 
16.7  per  cent.;  beeves  15.4  per  cent.;  calves  7.4  per  cent.;  and  goats  and  kids 
^10  of  I  per  cent.  This  tabulation  does  not  include  the  retail  trade.  The 
hygiene  of  this  industry  has  been  materially  improved  in  modern  establish- 
ments, but  is  still  quite  unsatisfactory  in  the  rural  districts  and  wherever 
primitive,  methods  are  in  vogue.  fThe  employment  involves  hard  work,  ex- 
r  posure  to  danipnes"Spandr^  UaBiIity  to  infection  from  diseases  communicable 
from  animals  to  man,  such  as  anthrax,  bovine  tuberculosis,  glanders,  tetanus, 
actinomj^cosis  (lumpy  jaw),  and  septic  conditions  of  cuts  and  abrasions. 
Butchers  who  are  in  the  habit  of  eating  raw  meats  may  become  infected  with 

jgworm  and  trichina. 

According  to  Ueiser,*  of  4200  male  butchers  in  Berlin,  during  the  3  years 
from  1902-1905,  an  average  of  2125,  or  about  50  per  cent.,  came  to  the  at- 
tention of  the  Sick  Insurance  companies.  Of  these  38.6  per  cent,  were  treated 
for  injuries  and  scalds  incident  to  the  trade;  19.2  per  cent,  for  sexual  diseases; 
7.2  per  cent,  for  diseases  of  the  respiratory  organs;  5.4  per  cent,  for  rheuma- 
tism; 4.7  per  cent,  for  skin  diseases,  chiefly  eczema  (the  last  two  groups  are 
largely  influenced  by  exposure  to  wet  and  drafts);  4.6  per  cent,  for  diseases 
of  the  digestive  system;  and  3.7  per  cent,  for  "flat-foot"  and  varicose  .ulcers, 
probably  caused  by  standing  too  long  on  their  feet.  The  excessive  rates  from 
sexual  diseases  may  be  due  to  more  frequent  exposure,  especially  as  animal 
food  stimulates  the  sexual  appetite  and  butchers  are  proverbially  well  fed. 

Preventive  Measures. — It  is  clearly  the  duty  of  the  State  to  exercise  a 
strict  sanitary  supervision  of  this  important  food  industry,  for  the  protection 
of  the  producer  and  consumer  alike,  and  this  supervision  should  extend  to 
the  smaller  establishments  in  the  country,  and   the   numerous   meat   and 


THE    INDUSTRY   OF   FOOD    STUFFS,    ETC.  69 1 

sausage  shops  in  the  city.  Wherever  unsatisfactory  conditions  are  found, 
they  should  be  removed  and  brought  up  to  the  standard  which  prevails  in 
clean,  decent,  and  properly  managed  establishments. 

Manufacture  of  Oleomargarine. — The  manufacture  of  oleomargarine 
originated  in  1868  with  Mege  Mouries,  a  chemist,  who  at  the  instigation  of 
the  French  Government  undertook  a  series  of  experiments  for  the  purpose 
of  securing  a  substitute  for  butter,  at  less  cost,  which  might  be  used  by  the 
army  and  navy  and  the  wage  earners  of  France.  The  original  process  of 
Mouries  was  patented  in  the  United  States  in  1873. 

The  product  consists  of  oleo  oil,  neutral  lard,  butter,  cream,  milk  and  salt. 
Refined  cotton-seed  oil  is  sometimes  used  in  limited  quantities  in  the  cheapest 
grades.  Oleo  oil  is  made  from  the  choicest  fat  of  the  beef.  It  is  taken  out 
of  the  animal,  washed  in  several  changes  of  water  and  placed  in  a  vat  of  ice 
water  to  stand  until  the  next  day.  It  is  then  cut  up  and  transferred  to  large 
steam-jacketed  kettles  in  which  it  is  boiled  under  constant  stirring.  It  is 
next  piped  to  kettles  on  the  floor  below,  where  it  is  clarified,  after  which  it  is 
conducted  into  tanks  on  the  floor  below  and  allowed  to  stand  until  the  stearin 
separates.  It  is  then  placed  in  linen  cloths  and  the  oil  is  extracted  in  a 
hydraulic  press  and  barreled.  The  residue  in  the  cloths  after  pressing,  com- 
mercially knowm  as  stearin,  is  utilized  for  the  manufacture  of  candles. 

Neutral  lard  is  obtained  from  the  leaf  lard  of  the  pig  and  after  thorough 
washing  is  placed  in  cold  storage  for  24  hours;  it  is  then  cut  up  into  shreds 
and  cooked  and  after  steaming  presents  a  snowy  white  appearance.  The 
oleo  oil  and  neutral  lard  in  the  proportion  of  about  27  per  cent,  of  the  former 
and  35  per  cent,  of  the  latter,  are  churned  with  cream  or  milk,  salted,  run 
through  cold  water,  worked  in  a  butter  worker,  placed  in  suitable  packages, 
and  labelled  according  to  the  U.  S.  Laws,  "Oleomargarine."  The  product  is 
subject  to  an  internal  revenue  tax  of  i  ct.  per  pound,  and  if  colored  to  re- 
semble butter  it  is  subject  to  a  tax  of  10  cts.  a  pound. 

Lard  Making.^Another  important  industry  carried  on  in  connection 
with  slaughtering  and  packing  houses  is  the  production  of  lard,  of  which 
there  are  several  kinds.  In  rendering  leaf  lard,  part  of  the  fat  separates  at 
a  temperature  between  105°  to  r2o°F.,  and  constitutes,  after  washing  with 
a  trace  of  sodium  carbonate,  common  salt  or  dilute  acid,  the  choicest  and 
richest  part  of  lard  known  as  neutral  lard— referred  to  in  the  preceding 
paragraph.  Leaf  lard  is  obtained  by  steam  heat  under  pressure  from  the 
residue,  after  the  neutral  lard  has  been  piped  off.  "Choice"  kettle  lard  is 
derived  from  the  remaining  portions  of  the  leaf  and  from  the  backs  of  the 
hogs.  Other  grades  of  lard  are  derived  from  the  head,  the  fat  of  the  small 
intestine  and  other  viscera,  trimmings  and  other  fatty  parts  and  is  sold  under 
the  euphonious  names  of  "prime  steam"  or  "refined"  lard. 

These  occupations  are  of  importance  as  the  process  of  rendering  animal 
fats  is  attended  with  the  evolution  of  fatty  acids,  such  as  palmitic,  stearic, 
oleic,  margarine  acids,  and  at  higher  temperatures  necessary  for  the  melting 


692        ETIOLOGY   AND   PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

of  tallow,  the  so-called  acrolein  vapors.  Under  certain  conditions  acetic 
and  butyric  acids,  and  also  ammonium  sulphide,  sulphuretted  hydrogen, 
pyridin,  picolin  and  lutiosin  may  be  evolved.  Acrolein  produces  itching  in 
the  throat,  irritation  of  the  eyes,  lachrymation,  conjunctivitis,  irritation  of 
the  upper  air  passages  and  bronchial  catarrh.  Dr.  Griin^  believes  that 
ingestion  of  fatty  acids  is  liable  to  produce  gastric  catarrh,  and  that  many  of 
the  diseases  of  the  stomach  in  this  class  of  workers  are  primarily  caused  by 
excessive  consumption  of  scraps  of  fat  meat  fished  out  of  the  rendering  kettles. 

Injuries  from  moving  machinery,  burns  and  infected  wounds  are  not 
uncommon,  and  erysipelas  occurs  sufficiently  often  to  justify  reference  by 
some  of  the  German  authors  to  such  terms  as  "margarine"  and  "tallow 
erysipelas"  and  "zoomotic  erysipeloid,"  meaning  thereby  that  the  infection 
is  conveyed  through  the  raw  products.  The  wound  infection  is  character- 
ized by  inflammation  of  the  lymphatics  and  glands,  and  a  moderate  tem- 
perature. It  can  scarcely  be  regarded  as  a  typical  streptococcus  infection, 
but  nevertheless  suggests  prompt  antiseptic  treatment  of  all  wounds  and 
abrasions. 

Preventive  Measures. — Copious  exhaust  ventilation  for  the  removal  of 
offensive  odors  and  gases. 

Dairy  Industry. — -The  exact  number  of  employees  in  this  industry  as 
a  whole  cannot  be  stated.  During  the  last  census  year  there  were  19,380 
persons  engaged  in  butter  factories;  7164  in  cheese  factories,  and  4962  in 
condensed  milk  factories.  The  average  number  of  female  wage  earners  was 
1420,  of  whom  987  were  in  the  condensed  milk  factories. 

The  hours  at  dairy  farms  if  not  long  are  unseasonable  and  involve  more 
or  less  night  work.  The  milkers  suffer  in  rare  instances  from  spasm  of  the 
flexors  of  both  hands  and  fingers.  Instances  of  infection  from  cowpox, 
tuberculosis,  from  handling  diseased  udders  or  infected  milk  or  cream,  ring- 
worm from  leaning  their  face  against  the  flank  of  an  affected  animal,  and 
occasional  cases  of  infection  with  the  germs  of  foot  and  mouth  disease  and 
actinomycosis,  or  lumpy  jaw,  have  been  reported. 

The  employees  in  dairies,  especialh^  those  engaged  in  the  pasteurizing 
and  bottling  departments,  are  exposed  to  a  damp  and  steamy  atmosphere 
and  the  work  under  foot  is  sloppy.  The  strong  borax  and  other  alkaline 
solutions  used  in  the  cleaning  of  bottles,  utensils,  etc.,  and  also  employed 
to  renovate  rancid  butter,  quite  frequently  produce  eczematous  conditions 
of  the  hands  and  arms,  unless  guarded  against  by  the  employment  of  ma- 
chinery and  rubber  gloves.  The  hygiene  of  persons  employed  in  the  manu- 
facture of  butter,  cheese,  or  condensed  milk  does  not  materially  differ. 

Preventive  Measures. — Fortunately  education,  legislation  and  com- 
petition have  done  much  to  reduce  the  dangers  to  a  minimum.  Neverthe- 
less watchful  care  is  still  needed  to  prevent  the  transmission  of  disease 
through  the  medium  of  milk  and  dairy  products.  This  is  true  not  only  of 
the  diseases  already  mentioned,  but  also  of  typhoid  fever,  diphtheria  and 


THE  INDUSTRY  OF  FOOD  STUFFS,  ETC.  693 

septic  sore-throat,  in  which  infection  takes  place  from  handling  of  the  milk 
by  bacillus  carriers,  or  by  washing  the  utensils  in  infected  water.  In  our 
present  state  of  knowledge  nothing  short  of  pasteurization  will  confer  im- 
munity from  so-called  milk-borne  diseases. 

The  Canning  and  Preserving  Industry. — The  average  number  of  per- 
sons engaged  in  this  industry  during  the  last  census  year'"  was  71,792  of 
whom  59,968  were  wage  earners;  of  these  over  one-half  were  females,  and 
4246  or  7.1  per  cent,  were  children  under  16  years  of  age.  The  census  covers 
four  classes  of  establishments,  viz.:  (i)  Plants  whose  chief  products  are 
canned  and  preserved  fruits  and  vegetables,  including  dried  and  packed 
fruits  put  up  in  packing  houses;  (2)  establishments  whose  chief  products  are 
canned  and  cured  fish,  including  pickled,  smoked  and  dried  fish;  (3)  estab- 
lishments whose  chief  products  are  canned  osyters  and  clams;  (4)  establish- 
ments whose  chief  products  are  pickles,  preserves,  jellies,  sauces,  etc. 

A  large  number  of  the  establishments  are  located  in  rural  districts.  The 
working  hours  are  irregular  and  often  very  long.  The  work  itself  is  sloppy 
and  involves  exposure  to  dampness,  and  in  the  cooking  and  packing  de- 
partment a  steamy  atmosphere  prevails,  which  upon  condensation  helps  to 
saturate  the  clothing  of  the  workers.  The  surroundings  are  often  extremely 
insanitary,  especially  in  the  jam  and  jelly  industry,  and  in  the  rural  districts 
the  temporary  camps  are  a  distinct  menace  to  the  health  of  the  people. 
The  work  of  lifting  and  carrying  buckets  or  baskets  weighing  from  40  to 
60  lb.,  from  the  supply  court  to  the  peeling  room  and  from  there  to  the 
canning  department,  is  not  an  easy  task  for  women  and  children,  who  re- 
ceive but  4  cts.  for  skinning  a  40-lb.  basket  of  tomatoes  and  a  similar  wage 
for  peeling  apples  and  fruit,  averaging  about  6.3  cts.  per  hour.  The  amount 
of  work  and  exposure  can  be  readily  judged  when  it  is  remembered  that  during 
the  rushing  season  some  of  the  employees  have  weeks  of  72  and  even  81  work- 
ing hours. ^^ 

As  a  result  of  long  hours  and  exposure,  catarrhal  affections  of  the  respira- 
tory passages,  rheumatism,  and  anaemic  conditions  are  by  no  means  infre- 
quent, and  sore  hands  and  cut  fingers  are  not  uncommon  sights.  The 
soldering  process  involves  exposure  to  lead  and  acid  fumes.  The  men 
employed  in  the  preservation  of  evaporated  fruit  are  also  exposed  to  the  fumes 
of  sulphurous  acid;  this  agent  is  also  employed  for  the  fumigation  of  hops. 

Preventive  Measures. — The  recommendations  referred  to  in  the  fish  in- 
dustry are  equally  applicable  to  canning  establishments.  There  is  no  reason 
why  mechanical  conveyors  and  machine  labor  should  not  supersede  much  of 
the  hand  labor.  Health  authorities  should  insist  that  hoods  and  exhaust 
drafts  for  steam  and  fume  processes  are  provided  and  that  the  equipment  and 
sanitary  arrangements  observed  in  some  of  the  establishments  are  made 
compulsory  for  all  others,  in  which  the  conditions  are  unsatisfactory.  Special 
attention  should  be  paid  to  the  sanitation  of  the  working  camps  in  rural 
districts. 


694        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

Breweries,  Distilleries  Etc. — A  number  of  operations  connected  with 
this  industry  involve  hard  work  and  exposure  to  extremes  of  heat  and 
humidity.  This  is  especially  true  of  the  malting  and  brewing  processes. 
The  work  of  turning  the  malt,  performed  in  a  temperature  between  158-176° 
is  laborious  and  should  be  displaced  by  automatic  machinery.  The  men 
engaged  in  the  brewing  department  are  exposed  to  the  combined  effects  of 
heat  and  humidity)  and  those  employed  in  the  coohng  rooms  to  a  temperature  . 
between  38°  and  40°;  hence  rheumatic  affections  are  quite  frequent,  amount- 
ing to  20-22  per  cent.,  against  15-16.5  per  cent,  in  other  occupations.  Work 
connected  with  the  fumigation  of  hops,  vats  and  casks  involves  exposure  to 
sulphurous  acid  fumes,  and  the  employment  of  ""salufer"  as  a  preservative 
and  antiseptic  may  prove  injurious  as  it  contains  about  2  per  cent,  of  sihco- 
fluoric  acid.  (See  also  Arsenic,  page  12.)  The  men  employed  in  the  fermen- 
tation vaults  are  exposed  to  large  volumes  of  carbonic  acid,  unless  special 
care  is  taken  for  the  liberation  of  these  gases.  This  is  Hkewise  true  of 
wine  cellars,  champagne  factories,  and  carbonated  water  bottling  estabHsh- 
ments.  Another  source  of  danger  in  breweries  and  distilleries  is  the  employ- 
ment of  wood  alcohol  as  a  solvent  for  the  shellac  to  coat  the  interior  of  large 
storage  casks  and  vats.  Quite  a  number  of  fatal  cases  from  this  cause  have 
been  reported  in  recent  years  in  New  York,  Buffalo  and  Chicago. 

The  death  rate  of  brewers,  distillers  and  rectifiers  in  this  country  during 
the  census  year  of  1900,  was  19.7  per  1000,  which  is  far  above  the  average 
of  other  occupations.  Tuberculosis  and  other  diseases  of  the  lungs,  heart, 
kidneys,  nervous  system  and  of  the  digestive  organs  lead  the  list.  This  we 
find  also  to  be  the  case  in  Great  Britain  and  Germany.  The  number  of 
deaths  from  tuberculosis  and  other  diseases  of  the  lungs  among  brewers  in 
Great  Britain  was  518  per  1000,  against  an  average  of  416  in  the  general 
population.  Sommerfeld  calculates  that  52.4  per  cent,  of  all  the  deaths  in 
brewers  are  caused  by  pulmonary  diseases,  inclusive  of  47.2  per  cent,  from 
consumption.  According  to  Weihrauch^^  36.4  per  cent,  of  all  the  deaths 
among  Munich  brewers  were  caused  by  tuberculosis,  19.7  per  cent,  by  heart 
disease,  ii.i  per  cent,  by  accidents,  8.02  per  cent,  by  diseases  of  the  kidneys, 
7.4  per  cent,  by  tumors,  etc.,  4.9  per  cent,  by  pneumonia  and  3.1  per  cent,  by 
typhoid  fever.     The  average  duration  of  life  is  about  32.6  years  (Koelsch).^^ 

The  Leipsic  statistics  show  a  morbidity  rate  for  brewers  and  malsters 
of  1 106  days  per  annum  per  100  workers  and  for  workers  in  yeast  factories 
863  days. . 

The  undue  prevalence  of  rheumatism,  diseases  of  the  lungs,  heart  and 
kidneys  may  in  part  be  due  to  exposure  incident  to  the  work,  but  the 
intemperate  habits  doubtless  play  even  a  more  important  role  in  their 
causation.     (See  also  the  alcohol  habit.) 

Preventive  Measures. — In  all  fermentation  processes  cases  of  asphyxia 
may  occur,  on  account  of  an  excess  of  carbon  dioxide  and  deficiency  of 
oxygen.     Such  instances  have  been  reported  in  breweries,  distilleries,  yeast 


THE    IXDUSTRY   OF   FOOD    STUFFS,    ETC.  695 

factories  and  bottling  establishments.  Hence  copious  ventilation  should 
be  provided  near  the  floor  level  for  the  removal  of  COo.  There  is  also 
danger  from  carbon  monoxide  and  arsenical  fumes  if  the  products  of 
combustion  are  allowed  to  pass  into  the  malt  or  other  drying  chambers. 

Modern  hot  air  kilns  and  automatic  malt-turning  machines  should  be 
provided.  Special  precautions  are  necessary  in  the  sulphuring  process  of 
malt  and  hops,  so  that  no  one  enters  until  after  thorough  ventilation  of 
the  premises,  the  efficiency  of  which  can  be  tested  by  holding  a  moistened 
strip  of  blue  htmus  paper  into  a  partly  opened  door,  this  will  turn  red,  if 
sulphurous  acid  fumes  are  still  present. 

Artificial  Ice. — The  manufacture  of  artificial  ice  by  the  ammonia  and 
brine  process  is  quite  generally  carried  on  in  connection  with  breweries 
and  cold  storage  plants.  The  work  is  wet  and  sloppy  and  involves  exposure 
to  very  low  temperature  (0-50°?.)  with  abrupt  changes.  In  most  of  the 
modern  plants  the  ice  is  handled  and  stored  by  machiner>',  but  injuries  are 
by  no  means  infrequent,  and  cases  of  poisoning  from  ammonia  fumes  are  not 
uncommon. 

Cold  Storage. — A  temperature  of  between  32°  and  4o°F.  combined  with 
excessive  humidity  is  inimical  to  health.  In  all  cold  storage  plants,  where 
ammonia  is  used  for  refrigeration  purposes,  special  precautions  are  necessary 
to  prevent  leakage  and  also  to  provide  helmets  or  an  oxygen  breathing  ap- 
paratus, suction  pumps,  etc.,  for  the  safety  of  the  workers  in  case  of  an 
accident. 

Vinegar. — In  the  manufacture  of  vinegar  there  is  frequently  escape  of 
acetic  acid  fumes,  alcohol,  aldehyde,  acetic  acid  ether  and  other  low  oxida- 
tion products  of  alcohol.  These  may  not  only  prove  injurious  to  the  health 
of  the  workers  but  constitute  an  economic  loss,  which  can  be  prevented  by 
the  employment  of  an  hermetically  closed  automatic  apparatus. 

Manufacture  of  Carbonated  Waters. — This  occupation,  apart  from  ex- 
posure to  large  quantities  of  carbon  dioxide,  involves  considerable  risk  of 
injuries  from  bursting  bottles,  as  a  result  of  gaseous  pressure  during  the 
bottling,  wiring  or  capping  process.  The  injuries  from  flying  glass  frag- 
ments may  involve  the  loss  of  an  eye,  or  serious  wounds  of  the  blood-vessels. 
The  work  is  often  carried  on  under  unfavorable  environment,  and  in- 
volves standing  in  the  wet  and  working  in  wet  clothes,  with  its  attending 
consequences. 

Preventive  Measures. — Copious  ventilation,  cement  floors  properly 
drained;  wooden  slat  floors,  wherever  wet  processes  are  carried  on;  water- 
proof clothing  and  rubber  boots;  and,  last  but  not  least,  suitable  wire  face 
guards  and  gauntlets. 

Spices. — The  grinding  and  packing  of  mustard,  pepper,  allspice,  nutmeg, 
vanilla,  etc.,  involves  exposure  to  irritant  dust  owing  to  the  presence  of 
essential  oils  and  alkaloids,  which  may  give  rise  to  catarrhal  conditions  of 
the  eyes  and  upper  air  passages,  and  also  in  some  instances,  notably  in  the 


696         ETIOLOGY    AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

manipulation  of  "vanillon,"  an  impure  specie  of  the  vanilla  bean,  to  irrita- 
tion and  inflammatory  conditions  of  the  skin. 

Chloride  of  Sodium. — The  manufacture  of  chloride  of  sodium  or  table 
salt  involves  exposure  to  a  moist  steamy  atmosphere,  during  the  evaporating 
process,  which  is  productive  of  catarrhal  conditions  of  the  upper  air  passages. 
The  effects  of  exposure  to  chlorine  are  evinced  by  the  fact  that  Mlilleri'* 
in  examining  165  salt  workers,  mostly  packers  and  grinders,  found  45  cases 
of  nasal  catarrh,  45  perforations  of  the  nasal  septum  and  9  recent  ulcers. 

A  peculiar  form  of  dermatitis  characterized  by  the  appearance  of  acne, 
redness,  and  oedema  of  the  face,  eyelids,  and  tips  of  the  ear  is  frequently 
observed  among  workers  in  the  drying  process.  This,  together  with  catarrhal 
symptoms  of  the  upper  air  passages,  loss  of  appetite,  and  digestive  derange- 
ments, is  attributed  to  the  irritant  vapors  of  hypochlorites  and  should  be 
guarded  against  by  hoods  and  copious  exhaust  ventilation. 

The  Tobacco  Industry. — The  cultivation  of  tobacco  and  its  subsequent 
storage  in  well- ventilated  barns  for  the  purpose  of  "curing"  may  be  regarded 
as  purely  agricultural  pursuits.  The  stripping  of  the  leaves  from  the  stalks, 
the  sorting,  drying  and  packing  and  unpacking  involves  more  or  less  inhala- 
tion of  dust  and  the  pungent  odors  of  tabacco.  The  work  in  the  "tobacco 
dryers"  involves  occasional  exposure  to  excessive  heat  and  the  inhalation  of 
fine  tobacco  dust  and  a  certain  amount  of  risks  from  dust  explosions  due  to 
the  greasy  and  inflammable  character  of  the  dust.  But  on  the  whole  none 
of  these  preliminary  processes,  according  to  the  Austrian  statistics,  appear 
to  be  as  detrimental  to  the  health  of  the  wage  earners  as  the  manufacture  of 
the  final  product.  This  is  probably  accounted  for  by  the  fact  that  the 
preliminary  processes  are  seasonal  in  character  and  the  exposure  of  a  com- 
paratively short  duration. 

Manufacture  of  Tobacco,  Cigars,  Cigarettes,  Etc. — This  industry  in  1905 
afforded  employment  in  the  United  States  to  159,408  wage  earners  of  whom 
57,174  or  42.2  per  cent,  were  females  and  5274  or  3.9  per  cent,  were  children 
under  16  years  of  age;  135,318  or  85  per  cent,  of  the  workers  were  engaged  in 
the  manufacture  of  cigars  and  cigarettes;  23,044  in  the  manufacture  of 
chewing  and  smoking  tobacco;  and  946  in  the  manufacture  of  snuffs.  Quite 
a  number  of  authors  state  that  the  manufacture  of  snuff  involves  the  greatest 
amount  of  fine  dust  production  but  this  is  an  evident  error  as  the  tobacco 
for  snuff  is  ground  up  in  a  moist  state.  The  manipulation  of  tobacco  in  a 
dry  state  results,  however,  in  more  or  less  dust  production;  this  is  especially 
the  case  in  the  unpacking,  the  separation  and  sorting  of  leaves  and  subsequent 
cutting  process  and  also  in  the  manufacture  of  cigars.  It  is  a  source  of  satis- 
faction that  the  use  of  machines  has  to  a  considerable  extent  displaced  hand 
labor  in  a  number  of  the  processes.  It  is  estimated  by  the  Bureau  of  Census, 
that  fully  85  per  cent,  of  the  cigars  and  nearly  all  of  the  cigarettes  are  now 
manufactured  in  this  country  by  machinery,  a  similar  revolution  has  taken 
place  in  the  manufacture  of  smoking  and  chewing  tobacco,  where  granulating, 


THE  TOBACCO  INDUSTRY,  ETC.  697 

shredding  and  packing  machines  perform  the  work  formerly  done  by  hand. 
There  is  no  doubt  that  these  modern  methods,  quite  apart  from  the  hygienic 
aspect  of  doing  away  with  the  objectionable  and  nasty  practice  of  finishing 
cigars  with  the  aid  of  saliva,  will  result  in  a  distinct  improvement  in  the 
health  of  the  employees.  On  the  other  hand,  it  must  not  be  forgotten  that 
the  preliminary  processes  and  even  the  use  of  machinery  unless  provided  with 
dust-removal  devices  will  still  involve  exposure  to  dust  containing  more  or 
less  nicotine.  This,  together  with  exposure  to  volatile,  pungent  tobacco 
odors  incident  to  the  various  processes  of  selection,  blending,  fermentation, 
flavoring  and  saucing  of  tobacco,  cannot  fail  to  prove  injurious. 

Heucke^^  examined  the  dust  in  diflferent  establishments  and  found  that  it 
contained  0.56  per  cent,  of  nicotine;  Stephani^*  calculates  that  a  cigar  maker 
in  turning  out  between  5-600  cigars,  each  weighing  10  grams,  manipulates 
in  close  proximity  to  his  mouth  and  nose  every  day  about  5  kg.  of  tobacco, 
containing  over  100  grams  of  nicotine  and  adds  that  when  it  is  considered 
that  the  /loo.ooo  part  of  this  amount  subcutaneously  injected  is  liable  to 
produce  serious  symptoms  of  nicotine  poisoning,  even  a  minimal  percentage 
in  the  dust  may  suffice  to  produce  specific  toxic  eflfects.  In  proof  of  this  he 
presents  Kostial's  observations,  showing  that  72  of  100  of  the  female  em- 
ployees in  a  Vienna  tobacco  factory  suffered  during  the  first  6  months  from 
congestive  headache,  palpitation  of  the  heart,  precardiac  anxiety,  weakened 
heart  action,  intermittent  pulse,  pain  in  the  stomach,  heart-burn,  vomiting, 
diarrhea,  loss  of  sleep  and  appetite,  neuroses,  general  fatigue  and  loss  of 
strength — a  clinical  picture  which  corresponds  to  that  observed  in  animal 
experimentation  with  nicotine. 

Much  has  been  said  and  written  concerning  the  health  injurious  factors 
in  this  occupation  and  opinions  dififer.  Some  authors  doubtless  overestimate 
the  risks;  others  deny  all  dangers;  indeed  some  authors  maintain  that  tobacco 
dust  exerts  a  protective  influence  against  infective  organisms,  and  instance 
the  fact  that  during  the  cholera  epidemic  of  Hamburg  in  1892  there  was  only 
8  cases  among  the  5000  resident  cigar  makers.  Be  this  as  it  may  the  statistics 
of  the  U.  S.  Census  Bureau  show  that  among  23  occupations  tabulated, 
cigar  makers  and  tobacco  workers  occupy  the  second  rank  in  the  mortality 
from  tuberculosis,  the  first  place  being  held  by  marble  and  stone  cutters. 

Hoffman's^*^  Industrial  Insurance  statistics  based  upon  141  deaths  from 
all  causes  show  a  mortaUty  of  34.8  per  cent,  from  consumption  and  9.9 
per  cent,  from  other  diseases  of  the  lungs,  which  is  far  in  excess  of  the  rates 
for  bakers,  confectioners  and  others  exposed  to  the  inhalation  of  vegetable 
dust.  The  Austrian  statistics  cited  by  Professor  Roth^^  and  based  upon  the 
morbidity  and  mortality  statistics  of  35,000  tobacco  workers  show  that 
among  the  causes  of  deaths,  tuberculosis  occupied  the  first  place,  other  dis- 
eases of  the  lungs  came  next,  followed  by  diseases  of  the  circulatory  and 
digestive  organs. 

As  evidence  of  the  specific  irritant  properties  of  tobacco  dust  Professor 


698        ETIOLOGY   AND   PROPHYL.\XIS    OF    OCCUPATIONAL   DISEASES 

Roth^^  refers  to  the  frequency  of  inflammatory  affections  of  the  skin,  eyes, 
throat  and  of  dental  defects.  Brauer  was  the  first  to  point  out  that  the  sharp 
angular  fragments  of  tobacco  dust  are  very  liable  to  produce  lesions  of  the 
mucous  membranes.  Among  the  surgical  diseases  Stephani^^  mentions 
felon  and  cellulitis;  he  also  points  out  a  very  low  accident  rate  in  tobacco 
workers.  Neuralgia  is  not  uncommon  and  a  peculiar  form  of  neuritis  affect- 
ing the  right  forearm  has  been  described  by  Kostial.^*  Galezowskii^  found 
cases  of  amblyopia  in  tobacco  workers  who  did  not  use  tobacco  in  any  form. 
De  Schweinitz^"  reports  the  case  of  a  young  woman  suffering  from  loss  of 
vision  whose  symptoms  disappeared  when  she  left  the  tobacco  factory. 
Dowling-^  reports  a  case  of  tobacco  amblyopia  in  a  woman  who  had  worked 
in  the  factory  for  5  or  6  years,  but  who  had  never  used  tobacco.  Such 
instances  are  doubtless  quite  rare.  Dr.  de  Schweinitz  writes  me  that  the 
woman's  work  involved  immersion  of  her  arms  for  several  hours  a  day  in  a 
rather  strong  solution  of  tobacco.  Diseases  pecuhar  to  women  were  twice 
as  frequent  than  among  workers  in  the  textile  industry;  chlorosis  and  anaemia 
are  also  frequently  observed. 

According  to  Rosenfeld  and  Picraccini,  female  tobacco  workers  are 
more  liable  to  miscarry.  While  this  confirms  the  conclusions  reached  by 
Dr.  Roger  S.  Tracy  of  New  York  as  early  as  1873,  it  is  at  variance  with  the 
results  of  an  investigation  made  at  Giessen,  a  German  tobacco  town,  in  1906, 
and  hence  more  extended  investigations  are  called  for.  The  latter  inquiry 
revealed,  however,  a  greater  frequency  of  post-partum  hemorrhages  and  a 
tendency  to  profuse  menstruation  among  this  class  of  workers.  The  sta- 
tistics presented  by  Stephani^^  covering  some  tobacco  towns  in  Baden  from 
1 889-1 901  also  indicate  an  undue  prevalence  of  tuberculosis.  In  1893  the 
German  government  promulgated  regulations  covering  the  installation  and 
operation  of  tobacco  factories  and  provided  a  minimum  air-space  of  7  cubic 
meters  which  was  increased  in  1907  to  10  cubic  meters  (353.16  cu.  ft.)  for 
each  worker.  Rules  concerning  ventilation,  the  removal  of  dust  and  the 
exclusion  under  certain  conditions  of  female  and  child  labor  were  also 
enacted. 

The  undue  prevalence  of  consumption  is  in  part  explained  by  the 
fact  that  many  weaklings  enter  upon  this  work;  while  this  must  be  conceded, 
as  well  as  the  fact  that  in  the  absence  of  adjustable  seats  and  work  benches 
the  constrained  position  of  the  workers  favors  a  predisposition  to  pulmonary 
diseases,  yet  the  same  is  true  of  youthful  confectioners  and  candy  makers, 
and,  although  likewise  exposed  to  the  inhalation  of  organic  dust,  these 
latter  show  a  much  lower  death  rate  from  diseases  of  the  lungs.  All  of  this 
tends  to  the  conclusion  that  we  are  dealing  not  only  with  the  inhalation 
of  irritant  vegetable  dust,  but  also  with  a  toxic  agent,  viz.,  nicotine,  the 
combined  effects  of  which  probably  account  for  the  lower  general  resisting 
power  to  disease. 

Tobacco  Testers. — Men  who  are  in  the  habit  of  sampling  different  brands 


THE  INDUSTRY  OF  FOOD  STUFFS,  ETC.  699 

of  tobacco  by  smoking  and  chewing  have  been  known  to  suffer  from  the 
effects  of  nicotine  poisoning,  and  like  tea  tasters  have  been  obliged  to  limit 
their  work  or  give  it  up  all  together  for  the  relief  of  nervous  symptoms  and 
visual  defects. 

^  Tea  Testing. — The  testing  of  tea  is  done  by  experts  in  the  tea  business. 
For  this  purpose  the  taster  sits  at  a  revolving  table  with  several  samples  of 
infused  tea  before  him;  he  takes  a  sip  of  the  tea  to  determine  its  aroma,  and 
after  rinsing  his  mouth  with  it,  expectorates  it.  In  spite  of  the  latter  pre- 
caution, possibly  because  of  the  numerous  tests  in  any  one  day,  more  or  less 
of  the  beverage  is  swallowed  or  absorbed  through  the  mouth  and  may  produce 
chronic  "thein  intoxication."  The  general  symptoms  of  this  condition  vary 
with  the  dosage  and  susceptibility  of  the  individual  and  are  characterized 
by  loss  of  appetite,  gastric  catarrh,  flatulent  dyspepsia,  constipation,  insomnia, 
irritability,  restlessness,  muscular  tremblings,  and  gradual  emaciation  and 
in  some  cases  also  discoloration  of  the  finger  nails.  Similar  symptoms 
are  observed  in  so-called  tea  and  coffee  topers,  but  fortunately  the  effects, 
like  those  of  alkaloidal  beverages  in  general,  appear  to  be  functional  in 
character  and  pass  off  by  removal  of  the  cause. 

Hotel,  Restaurant,  Saloon-keepers,  Etc. — These  occupations  include  a 
large  number  of  employees,  both  male  and  female,  from  bell  boys  of  the  age 
of  14,  to  veterans  in  the  army  of  waiters,  cooks,  porters,  housemaids,  etc. 

While  we  have  no  statistical  data  in  this  country  which  would  serve 
to  emphasize  the  injurious  effects  on  the  employees  as  a  whole,  the  sta- 
tistics of  Great  Britain  and  of  Berlin  clearly  indicate  that  this  class  of  workers 
has  an  unusually  high  morbidity  rate. 

Dr.  Gast^^  informs  us  that  of  18,133  members  of  the  Berlin  Union,  includ- 
ing the  various  classes  of  employees,  there  were  19,856  admissions  a  year 
on  the  sick  report,  with  an  average  duration  of  28.9  days,  which  is  con- 
siderably higher  than  among  other  occupations. 

Of  these  there  were  2308  cases  of  diseases  of  the  digestive  organs  2087 
cases  of  diseases  of  the  respiratory  organs,  204  of  tuberculosis,  2074  cases 
suffered  from  diseases  of  the  motor  system  inclusive  of  103 1  cases  of  mus- 
cular rheumatism,  and  318  cases  of  "flat-foot"  and  deforinities  of  the  knee; 
1585  suffered  from  accidents;  1417  from  sexual  diseases;  1016  from  mental 
and  nervous  diseases;  loii  from  chlorosis  and  anaemia;  660  from  blood  poi- 
soning and  celluhtis;  564  from  diseases  of  the  heart  and  blood-vessels,  in- 
clusive of  228  cases  of  varicose  veins;  314  contracted  occupational  eczema; 
212  had  ulcers  of  the  legs;  and  45  suffered  from  chronic  alcoholism  and 
delirium  tremens. 

The  general  mortality  rate  was  7.16  per  1000;  45.5  per  cent,  of  all  the 
deaths  were  caused  by  diseases  of  the  lungs,  including  consumption.  The 
deaths  from  diseases  of  the  heart  and  kidneys  were  in  excess  of  those  in 
other  occupations.  The  three  principal  causes  of  death  and  also  the  undue 
prevalence  of  these  diseases  are  doubtless  influenced  by  the  alcohol  habit. 


700        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

The  occupation,  in  general,  involves  long  and  irregular  hours  of  work  in 
a  vitiated  atmosphere,  often  contaminated  by  tobacco  fumes.  Many  of 
the  employees  are  weaklings  and  have  inferior  sleeping  quarters.  Pro- 
longed standing  and  walking  naturally  favor  the  development  of  "flat-foot" 
and  "knock-  and  in-knee"  in  the  young,  and  of  varicose  veins  and  leg 
ulcers  in  the  older  class  of  employees.  Schultes^^  has  shown  that  of  14,000 
recruits  examined  12.7  per  cent,  suffered  from  flat-foot  and  varicose  veins, 
mostly  waiters  or  salesmen,  while  occupations  involving  sedentary  habits 
furnished  practically  no  cases.  Cooks  in  general  are  exposed  to  excessive 
temperatures  and  this  is  especially  true  of  men  connected  with  the  dining-car 
service,  where  cases  of  heat  exhaustion  are  not  uncommon. 

Preventive  Measures. — It  would  indeed  be  interesting  to  present  Ameri- 
can statistics  for  comparison.  It  is  evident,  however,  from  general  observa- 
tions that  the  lot  of  this  class  of  employees  is  far  from  satisfactory  and 
shorter  working  hours,  not  exceeding  8  out  of  24  hours,  better  working  con- 
ditions and  pay,  so  as  to  enable  them  to  enjoy  their  much  needed  rest,  is 
certainly  indicated. 

Copious  ventilation  in  cafes  and  restaurants,  which  permit  smoking,  and 
general  sanitation  of  the  kitchens  and  serving  departments,  will  benefit 
the  patrons  and  employees  alike.  Persons  under  the  age  of  18  should  not 
be  employed  for  night  duty. 

Domestic  and  Personal  Service. — -The  United  States  mortality  statistics 
of  this  class  of  wage  earners  including  barbers,  bartenders,  janitors  and  sex- 
tons, servants  and  waiters  and  laborers  not  specified,  show  high  rates  from 
tuberculosis  and  pneumonia. 

The  rates  are  especially  excessive  in  janitors  and  sextons,  barbers,  servants 
and  waiters.  The  general  servant,  as  a  result  of  long  hours  and  indoor  life, 
becomes  anaemic,  and  is  liable  to  suffer  from  headache,  constipation  and  diges- 
tive derangements,  including  gastric  ulcer.  Varicose  veins  and  ulcers  of  the 
leg,  and  "flat-foot"  from  prolonged  standing  are  not  infrequent. 

Barbers  and  Hair  Dressers. — ^In  view  of  the  fact  that  many  weaklings 
engage  in  this  employment,  it  is  not  surprising  that  the  tuberculosis  death 
rate  of  barbers  is  rather  high.  Catarrhal  affections  of  the  upper  air  passages, 
digestive  disorders,  "flat-foot"  and  eczema,  the  latter  as  a  result  of  contact 
with  hot  water  and  toilet  preparations,  are  not  uncommon.  Razor  cuts  of 
the  fingers  occur  occasionally,  but  on  the  whole  it  cannot  be  said  that  the 
occupation  is  inimical  to  health.  The  Leipsic  Insurance  statistics  show  a 
morbidity  of  395  days  per  100  members  per  annum  and  a  mortality  hazard 
of  only  0.32  per  cent. 

Robinson  and  Wilson^*  inspected  two  bakeries  in  Cincinnati  and  found  only  one  case  of 
tuberculosis  among  134  examined,  and  this  man  a  porter  had  been  working  in  the  bakery 
only  3  months. 

The  conditions  in  the  bakeries  were  excellent,  although  many  of  the  bakers  were  pale, 
due  to  excessive  perspiration  and  heat.  The  kneading  is  all  done  by  machinery  and  the  air 
is  washed  and  humidified,  before  it  enters  the  mixing  rooms.     The  workmen  are  required 


THE    INHDUSTRY   OF   FOOD    STUFFS,    ETC.  70I 

to  bathe  and  change  from  their  street  clothing  into  white  uniforms.  Promiscuous  spitting 
is  prohibited.  Among  352  workers  in  the  confectionery  and  cake  industries,  but  two  cases  of 
tuberculosis  were  found.  The  sanitary  and  hygienic  conditions  in  the  four  establishments 
visited  were  good  in  all,  except  that  the  temperature  of  the  rooms  in  which  the  candies 
are  packed  is  artificially  cooled,  which  in  summer  may  prove  injurious  on  account  of  the 
sudden  change  from  the  high  temperature  of  the  street. 

Out  of  204  brewers  examined  four  or  1.9  per  cent,  were  tuberculous.  In  none  of  the  four 
cases  was  alcoholism  or  occupation  hazard  most  in  evidence  as  a  predisposing  cause.  The 
high  wages,  reasonable  working  hours,  good  home  conditions  and  the  high  standard  of 
sanitary  conditions  in  the  breweries,  are  factors  tending  to  lessen  the  occupational  hazards. 

Of  295  males  and  25  females  employed  in  slaughtering  and  meat  packing,  only  two  cases, 
or  0.62  per  cent,  of  those  examined  presented  evidence  of  tuberculosis.  This  low  percent- 
age in  the  face  of  inimical  working  conditions,  such  as  a  steamy  atmosphere,  wet  floors, 
extremes  of  temperature,  is  attributed  to  the  employment  of  robust  men,  and  the  law  pro- 
hibiting tuberculous  persons  from  working  in  abattoirs. 

Among  94  restaurant  employees  examined  three  were  found  to  be  tuberculous,  although 
none  was  an  open  case.  Six  others  appeared  strongly  predisposed  to  the  development  of 
the  disease.  Taken  as  a  whole  the  group  of  workers  presented  an  appearance  of  poorer 
physical  condition  than  any  other  class  examined.  As  there  is  nothing  in  the  work  itself 
that  should  cause  tuberculosis,  the  investigators  concluded  that  those  who  through  failing 
health  or  because  of  drink  and  dissipation  had  failed  in  other  work,  naturally  seek  employ- 
ment in  cafes  or  restaurants. 

Of  254  male  and  377  female  operatives  in  the  cigar  industry,  only  three  were  found  to  be 
tuberculous,  although  the  industry  has  been  considered  to  be  dangerous  through  the  in- 
halation of  tobacco  dust.     However,  many  of  the  workers  appeared  anaemic. 

REFERENCES 

^  State  College  of  Wash.  Agric.  Exper.  Station,  Pullman,  Wash.,  Bull.  Xo.  117,  Novem- 
ber 3,  1914. 

2  Hoffman,  F.  L. — Bulletin  Bureau  of  Labor,  No.  82,  May  1909,  page  502. 

3  Editorial,  J.  A.  M.  A.,  December  12,  1914,  page  2137. 

*  Hoffman,  F.  L. — Bulletin  Bureau  of  Labor,  No.  82,  May,  1909,  page  534. 

^  Roth. — Gewerbehygiene,  Leipzig,  1907,  page  132. 

^  Neisser. — Internat.  tjbersicht  d.  Gewerbehygiene,  Berlin,  1907. 

'  Oliver's  Dangerous  Trades,  1902. 

^Leiser. — Weyl's  Handbuch  d.  Arbeiterkrankh.,  Jena,  1908,  page  442. 

5  Griin,  Heinrich. — Weyl's  Handbuch  d.  Arbeiterkrankh.,  Jena,  1908. 
"  Statistics  for  Canning  and  Preserving.     Census  of  the  U.  S.,  1910. 
"  Bulletin  of  the  Bureau  of  Labor,  No.  96,  Sept.,  1911,  pages  3S3-3S6,  Washington,  D.  C. 
12  Weihrauch. — Inaugural  Dissert.,  Miinchen,  1905. 

15  Koelsch. — Krankheit  und  Soziale  Lage,  Miinchen,  1913,  i  Liefs,  page  215. 
"  MuUer.— Vierteljahrschr.  f.  Ger.  Med.,  Bd.  Ill,  IX,  page  381. 
15  Heucke,   cited    by  Stephani. — Weyl's  Handbuch  d.   Arbeiterkrankheit.,   Jena,    1908, 

pages  634-635. 
"  Hoffman,  F.  L.— Bulletin  of  Labor,  No.  82,  Washington,  May,  1909,  page  569. 
1^  Roth,  E. — Gewerbehygiene,  Leipzig,  1907. 

18  Kostial,  cited  by  Stephani.— Weyl's  Handbuch  d.  Arbeiterkrankh.,  1908,  page  637, 
"  Galezowsky.— Des  ambly  op.  et  Amauroses  toxigues,  1897.     Cited  by  Oliver. 

20  The  Toxic  Amblyopias,  etc.,  1896,  pages  59-79- 

21  Cincinnati  Lancet  Clinic,  1892,  Vol.  XXX,  pages  585-59°- 

22  Gast.— Weyl's  Handbuch  der  Arbeiterkrankheiten,  Jena,  1908,  page  445. 
"  Schultes. — Deutsch.  Med.  Wochenschrift,  1901,  No.  32. 

"  Robinson,   D.   E.,   and  Wilson,   J.  G.— U.  S.  Public  Health  Bulletin   No.  73,  March, 
1916,  page  22. 


CHAPTER  XVI 
LIBERAL  PROFESSIONS,  PUBLIC  SERVICE  EMPLOYEES,  ETC. 

BY  GEORGE  M.  KOBER.  M.  D.,  Washington,  D.  C. 

Clergymen.  Physicians.  Veterinarians.  Trained  Nurses.  Sisters  of  Charity.  School 
Teachers.  Lawyers.  Artists.  Public  Speakers,  Singers,  etc.  Musicians.  Soldiers, 
Sailors,  Pilots,  etc.  Fire  and  Police  Department  Employees.  Stationary 
Firemen  and  Engineers.  Commercial  and  Mercantile  Pursuits.  Telephone 
and  Telegraph  Service.  Elevator  Employees.  Railway  Service  and  Acci- 
dents. Street  Railway  Employees.  Subway  Employees.  Automobilists.  Dray- 
men. Hackmen  and  Teamsters.  Street  Cleaners,  Ice,  Coal  and  Ash  men  and 
General  Day  Laborers.     Preventive  Measures. 

Liberal  Professions. — These  include  clergymen,  lawyers,  physicians  and 
surgeons,  teachers,  nurses,  artists  and  musicians.  The  morbidity  and  mor- 
tality statistics  in  all  these  occupations,  considering  the  indoor  and  sedentary 
employment,  are  quite  normal.  Mortality  statistics  very  generally  indicate 
that  clergymen  have  the  greatest  expectation  of  life.  According  to  the 
statistics  cited  by  Koelsch,  protestant  ministers  enjoy  a  higher  longevity  than 
priests,  who,  however,  have  about  the  same  morbidity  and  mortality  rates 
as  bachelors  of  the  same  age  periods.  Among  the  principal  causes  of  death 
among  clergymen  are  diseases  of  the  heart,  kidneys  and  apoplexy.  The 
tuberculosis  death  rate  in  1908  in  Bavaria  among  this  class  was  1.84  against 
3.07  per  1000  in  the  occupied  male  population. 

The  mortality  of  physicians  and  veterinarians  is  generally  higher  than 
in  the  other  liberal  professions,  but  not  in  excess  of  the  occupied  male  popula- 
tion of  the  same  ages,  except  in  diseases  of  the  circulatory  and  nervous  system, 
and  the  infectious  diseases.  This  is  in  part  due  to  a  life  full  of  exposure  and 
responsibility,  and  Koelsch  suggests  that  in  some  instances  the  tobacco  and 
drug  habits  may  play  a  role.  The  tuberculosis  death  rate  in  Bavaria  among 
physicians  is  quite  low,  viz.,  1.92  against  3.07  per  1000  in  the  occupied  male 
population.  We  have  no  mortality  statistics  concerning  " /rcm^(/  nurses,'' 
and  even  the  German  statistics  cover  chiefly  reUgious  orders  of  those  who 
consecrate  their  life  to  the  care  of  the  sick.  According  to  Cornet  and  Koelsch 
from  55-66  per  cent,  of  the  sisters  of  Charity  perish  from  tuberculosis,  as 
compared  with  a  rate  of  39.6  per  cent,  in  the  general  female  population. 
Among  the  chief  predisposing  causes  are  doubtless  the  indoor  life,  insufficient 
exercise  in  the  open  air,  deficient  air-space  of  sleeping  quarters,  contact 
infections,  night  duty  and  frequent  fasting. 

The  condition  of  the  sisters  who  devote  their  lives  to  teaching  is  almost 
as  unsatisfactory  as  regards  the  prevalence  of  tuberculosis. 

The  mortality  rates  among  school  teachers,  the  majority  of  whom  are  fe- 
males in  this  country,  are  quite  favorable,  and  among  the  German  male 

702 


LIBERAL   PROFESSIONS,    ETC.  703 

teachers  approximate  very  closely  to  those  of  the  protestant  clergy.  The 
tuberculosis  death  rate  in  Bavaria  was  1.3  for  males  and  1.55  per  1000  for 
female  teachers,  which  is  far  below  the  average  rate.  Higher  rates  have 
been  reported  by  Schmidt  of  Dlisseldorf,  and  our  American  statistics  also 
indicate  that  school  teachers  are  slightly  more  lial)le  to  tuberculosis  than 
members  of  the  other  learned  professions. 

This  is  doubtless  due  to  indoor  life,  confinement  in  badly  ventilated  school 
rooms  and  the  presence  of  dust.  Diseases  of  the  nervous  system  and 
uterine  organs  are  also  quite  common,  and  teachers  will  do  well  to  insist 
upon  proper  seats,  absolute  cleanliness  of  the  schoolroom,  fresh-air  schools, 
or  at  least  copious  ventilation,  and  substitution  of  wet  for  dry  methods  of 
removing  chalk  markings. 

The  mortality  rates  of  lawyers  are  quite  favorable,  although  not  quite 
as  good  as  those  of  ministers,  teachers  and  artists;  their  consumption  rate 
in  the  British  statistics  is  11.6  as  compared  with  27.2  among  their  office 
employees.  The  latter,  in  addition  to  indoor  work,  are  doubtless  exposed 
like  so  many  other  bureau  and  library  employees  to  the  inhalation  of  very 
fine  dust,  and  as  a  protection  against  this  the  general  introduction  of  dust- 
proof  file  cases  and  cleaning  by  the  vacuum  system  should  be  invoked. 

The  mortality  rates  among  artists  are  quite  satisfactory,  but  those  of 
musicians  are  far  below  the  average,  due  as  suggested  by  Koelsch  to  a 
precarious  existence  and  "a  life  full  of  temperamental  conditions." 

Public  speakers,  clergymen,  singers,  etc.,  are  liable  to  suffer  from 
chronic  affections  of  the  throat  and  paralysis  of  the  vocal  chords. 

Musicians. — -Pianists  and  violinists  not  infrequently  suffer  from  spasm 
and  fatigue  neurosis  of  the  fingers  and  forearms;  flutists  have  been  known  to 
suffer  from  laryngeal  spasm,  and  performers  on  wind  instruments  from  spasm 
of  the  tongue  and  laryngeal  muscles.  Formerly  it  was  held  that  emphysema 
was  quite  common  in  military  musicians,  but  Fischer  did  not  find  a  single  case 
among  the  500  brass  instrument  performers  examined  by  him,  and  Professor 
Gairdner  never  saw  a  case  among  the  Scotch  bagpipe  players. 

Aldrich  has  described  a  peculiar  neurosis,  characterized  by  a  cramp-like 
and  burning  pain,  fatigue  and  a  sense  of  constriction  in  the  muscles  of  the 
right  leg  below  the  knee,  caused  by  operating  a  "trap  drum"  by  means  of  a 
pedal,  which  gave  him  free  use  of  both  hands  to  play  other  drums,  triangle 
and  "traps."  The  pedal  mechanism  required  a  pressure  of  from  5  to  25 
lb.  for  each  stroke;  to  play  the  drum  required  at  times  180  strokes  per 
minute,  and  it  is  perfectly  conceivable  how  the  excessive  use  of  certain  mus- 
cular groups  of  the  right  leg  should  be  responsible  for  this  type  of  fatigue 
neurosis.  Von  Wurthenau,  cited  by  Dr.  J.  R.  Hunt,*  has  collected  62  cases 
of  "drummers'  paralysis,"  which  is  an  extensor  paralysis  of  the  distal  phalanx 
of  the  thumb,  occurring  usually  in  beginners  and  exclusively  on  the  left  side. 
The  condition  is  the  result  of  a  chronic  tenosynovitis  induced  by  a  peculiar 
method  of  holding  and  using  the  left  drumstick,  causing  a  mechanical  irrita- 


704 


ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 


tion  of  the  long  extensor  tendon  of  the  thumb,  and  subsequent  pathologic 
alterations  in  the  tendon  and  its  sheath  and  eventually  a  rupture  during  a 
paroxysm  of  drumming  or  more  rarely  quite  spontaneously. 

Dr.  Hunt^  has  recorded  a  case  which  occurred  in  a  tailor  in  whom  the 
daily  use  of  a  coarse  heavy  needle  and  pressing  irons  evidently  induced  the 
pathological  change. 

Preventive  Measures. — The  learned  professions,  whose  work  is  to  a  great 
extent  mental,  need  physical  exercise,  such  as  golf,  lawn  tennis,  etc.,  which 
are  calculated  to  counteract  the  evil  effects  of  a  sedentary  and  indoor  life. 
The  benefits  derived  from  office  and  house  sanitation,  general  cleanliness, 
and  ventilation,  personal  health  rules  as  regards  food  and  drink,  and  tem- 
perate habits  in  all  things  should  not  be  underrated. 

Soldiers. — The  hygiene  of  soldiers,  sailors,  and  members  of  the  Police 
and  Fire  Departments  is  not  without  interest  as  they  are  usually  able-bodied 
men  and  have  to  undergo  a  physical  examination  prior  to  enlistment.  The 
health  of  the  United  States  Army  has  steadily  improved  during  the  past 
three  decades,  as  shown  by  a  reduction  in  the  mortality  rate  from  7.54  per 
1000  in  1885  to  4.79  per  1000  in  191 2.  The  majority  of  the  men  are  re- 
cruited from  the  rural  districts  and  in  point  of  physique  and  morale  compare 
most  favorably  with  any  army  in  the  world.  The  percentage  of  rejection 
for  physical  defects  is  only  12,  which  is  far  below  the  average  in  other  coun- 
tries. The  food,  clothing,  quarters  and  general  sanitation  in  the  United 
States  public  services  are  very  satisfactory.  The  medical  officers  have 
realized  long  since  that  their  chief  function  lies  in  preventive  medicine, 
and  profiting  by  the  experience  that  many  soldiers  are  lost  in  the  making, 
there  is  no  disposition  to  overdo  the  training  of  the  recruit.  Surgeon  General 
Stokes,  a  few  years  ago,  sounded  a  note  of  warning  against  overtaxing  the 
officers  and  men  in  the  Navy.  The  tendency  is  in  the  direction  of  steady 
physical  gains  and  the  percentage  of  recruits  who  breakdown  during  the 
first  year  of  enlistment  is  very  small.  The  prevention  and  correction  of  flat 
feet  has  received  attention  not  only  by  proper  shoes  but  also  by  proper 
posture  and  proper  gait  (see  flat-feet). 

The  mortaHty  of  the  enlisted  men,  American  troops  in  the  United  States 
Army  according  to  location  between  1906-1913,  is  given  by  the  office  of  the 
Surgeon  General  U.  S.  Army  as  follows: 


Locality 


Mean  strength, 
exposed  i  year 


Deaths 


Rate  per 
1000 


Philippine  Islands 98,211 

United  States 414,783 

Panama  Canal  Zone* i,774 

Alaska '  8,635 

Hawaii 14,666 

*  First  Army  Hospital  opened  in  October,  191 1. 


644 

2,038 

13 

43 

51 


PUBLIC    SERVICES,    SOLDIERS,    SAILORS,    ETC. 


705 


The  morbidity  and  mortality  rates  are  very  satisfactory,  except  that  the 
admission  rates  for  venereal  diseases  and  alcoholism  arc  still  excessive.  The 
primary  cause  may  be  looked  for  in  idleness,  and  while  much  has  been  done 
by  athletic  sports,  educational  methods  and  genteel  amusements,  calculated 
to  counteract  the  evil  effects  of  saloons  and  prostitution,  more  may  be  done 
by  the  employment  of  trained  soldiers  on  extra  duty  for  mechanical  work. 
The  admission  rate  for  alcoholism  has  been  reduced  from  35  per  1000  in 
1907  to  15  per  1000  in  19 13,  and  for  venereal  diseases  from  168  per  1000 
in  191 2  to  97  in  1913.  The  typhoid  fever  rate,  the  scourge  of  all  armies  has 
been  reduced  from  5.46  in  1903  to  0.05  per  1000  in  1913.  This  is  the  result 
of  improved  sanitation,  but  chiefly  a  direct  effect  of  anti-typhoid  vaccination, 
introduced  in  the  United  States  Army  in  1909. 

The  tuberculosis  and  pneumonia  death  rates  in  the  United  States  Army 
have  been  reduced  respectively  from  0.95  and  0.48  in  1901  to  0.49  and  0.28 
in  1913.  This  is  largely  due  to  the  increased  cubic  air  space  in  military  bar- 
racks. Sir  Thomas  Oliver  states  that  the  phthisis  death  rate  in  the  British 
Army  was  reduced  from  7.82  to  2.5  per  1000  in  the  course  of  5  or  6  decades. 

Col.  H.  M.  Dean  of  the  Britsh  Army  Medical  Corps,  cited  by  Oliver, 
believes  that  the  soldier's  irritable  heart,  first  described  by  Da  Costa  of  this 
country,  is  largely  the  result  of  standing  "at  attention,"  with  his  chest  ad- 
vanced, walls  fixed  and  the  abdomen  retracted.  Such  a  position  naturally 
impedes  inspiration  and  expiration,  and  the  blood  tends  to  accumulate  in  the 
right  side  of  the  heart  and  venous  system.  The  pulse  rate  is  often  increased 
from  80  to  100  and  even  132  per  minute,  and  he  believes  that  "the  mischief 
done  to  the  recruit  on  the  parade  ground  can  be  stopped  by  abolishing  the 
present  position  of  'attention'  and  giving  short  plain  instructions  as  to  how 
to  stand  erect  without  constraint." 

Navy  and  Marine  Corps.— The  hygiene  of  the  public  services  is  quite 
satisfactory,  as  shown  by  the  following  comparative  mortality  statistics  of 
the  United  States  Army  and  Navy: 


Principal  causes  of  death 


Army  rate  per  10,000      I      Navy  rate  per  10,000 


1906 


1906 


Accidents |  15  •  7 

Tuberculosis 7-7 

Respiratory  diseases 3.1 

Digestive  diseases S-o 

Circulatory  diseases j  2.7 

Suicides j  6.7 

Genito-urinary  diseases 1.4 


22.1 

4-4 
1.8 
3-2 
3-5 


14.2 
4-5 
3.6 

2-5 

2.2 
2.1 
1.9 


The  sailors'  greatest  enemies  are  darkness,  dampness,  insufficient  air-space 
in  the  sleeping  quarters,  exposure  to  extremes  of  heat  and  cold,  irregular 
45 


7o6        ETIOLOGY   AND    PROPHYLAXIS    OF   OCCLTATIONAL  DISEASES 

sleeping  hours,  hard  work  and  accidents,  especially  during  storms.  As  a 
result  we  see  an  undue  prevalence  of  injuries,  diseases  of  the  respiratory- 
organs,  rheumatic  and  neuralgic  affections.  Cases  of  heat  exhaustion  are 
not  uncommon  in  stokers  and  engineers,  especially  in  the  tropics.  Venereal 
diseases  and  alcohoHsm  are  still  quite  frequent,  although  the  admission  rate 
from  alcoholism  has  been  reduced  from  5.28  per  1000  in  1907  to  3.45  in 
1 9 13.  Tropical  diseases  naturally  help  to  swell  the  general  mortality  rate, 
which,  however,  has  been  reduced  from  11.85  P^r  1000  in  1885  to  6.22  in 
1 9 10.     For  further  details  see  page  710. 

Among  the  occupational  risks  in  the  United  States  Navy,  Surgeon  General 
Stokes  refers  to  the  injurious  effects  of  carbon  monoxide,  which  develops  in 
gun  firing  in  the  turrets  of  battleships,  and  believes  that  this  gas  in  the 
furnace  rooms  gives  rise  to  acute  poisoning,  often  mistaken  for  heat  pros- 
tration. He  has  also  called  attention  to  the  serious  injury  inflicted  upon  the 
retinas  and  optic  nerves  of  men  who  have  to  operate  strong  search-lights, 
and  has  further  pointed  out  that  gunners,  who  use  telescopes,  to  point  the 
big  guns  in  the  turrets,  soon  fall  8  or  10  below  normal  vision. 

Merchant  Marine  Service,  Etc.- — We  have  no  separate  statistics  for  sailors 
in  this  country.  The  United  States  census  gives  the  death  rate  for  "sailors, 
pilots,  fishermen  and  oystermen"  at  22  per  1000  in  1890,  and  27.7  in  1900; 
for  "boatmen  and  canalmen"  the  rates  were  20  in  1890,  18.8  in  1900  and 
22.9  per  1000  in  1909.  Of  14,469  cases  treated  in  the  Marine  Hospitals 
during  the  fiscal  year  ended  June  30,  1914,  there  were  2579  general  and  local 
injuries  with  25  deaths,  and  11,890  cases  of  sickness  with  431  deaths.  In 
addition  38,757  cases  were  treated  in  the  dispensaries,  of  which  6816  were 
for  injuries  and  31,941  for  diseases.  Of  the  total  number  there  were  8601 
cases  of  venereal  diseases,  7219  cases  of  diseases  of  the  digestive  system,  3104 
cases  of  diseases  of  the  respiratory  system,  2731  cases  of  rheumatism, 
1361  cases  of  nervous  diseases,  and  870  cases  of  diseases  of  the  circulatory 
system. 

Ratio  of  Deaths  from  Specific  Causes  in  the  U.  S.  Merchant  Marine  Service 

1906  1914 

General  diseases 51-52  48.23 

Diseases  of  the  nervous  system .'....  4.87           6.39 

Diseases  of  the  circulatory  system 11. 16  14-53 

Diseases  of  the  respiratory  system 9- 13           9-25 

Diseases  of  the  digestive  system 5 .  88          5 .  28 

Genito-urinary  system 6 .  09           7 .  93 

Injuries 9.13           5.52 

From  all  other  causes 2.22           2.86 

The  mortality  rate  of  the  British  Merchant  Service  given  by  Oliver^ 
for  1898-99  was  9.6  per  1000,  of  which  7.4  were  caused  by  injury  and  2.2 
from  disease.  The  corresponding  rate  in  the  Royal  Navy  for  1899  was  4.9 
per  1000  made  up  of  1.35  from  injury  and  3.56  from  disease,  showing  what  can 


PUBLIC    SERVICES,    FIRE    AND   POLICE   DEPARTMENT 


707 


be  done  by  rigid  discipline,  and  prompt  medical  attention  in  the  prevention 
of  fatal  accidents. .  The  same  author  states  that  cases  of  thoracic  aneurism, 
as  a  result  of  hard  work,  sudden  strain  and  syphilis,  also  of  violent  knocks  and 
bruises  of  the  chest  received  during  gales,  are  quite  common. 

The  occupational  hazards  of  pilots,  fishermen  and  oystermen  do  not 
differ  essentially  from  those  of  sailors.  Exposure  to  all  kinds  of  weather, 
long  hours,  irregular  meals  and  accidents  from  sudden  squalls  naturally 
render  an  otherwise  healthful  out-door  occupation  dangerous. 

The  members  of  the  Life  Saving  Service^  encounter  even  greater  occupa- 
tional risk  than  pilots  and  fishermen.  The  average  age  of  station  keepers  in 
1910  was  51  years  and  of  surfmen  38  years.  The  fatal  accident  mortality 
in  1880,  in  a  force  of  1167,  was  5.14  per  1000  and  in  1910  with  a  mean 
strength  of  2204  it  was  only  0.45  per  1000. 

Fire  and  Police  Department  Employees. — The  men  employed  in  the  fire 
department,  like  all  other  workers,  exposed  to  excessive  heat,  sudden  changes 
in  temperature,  wet  and  cold  are  predisposed  to  rheumatic,  neuralgic  and 
catarrhal  affections,  muscular  cramps  and  diseases  of  the  respiratory  organs. 

In  addition  to  the  injurious  factors  common  to  all  firemen  they  are  not 
infrequently  exposed  to  the  inhalation  of  hot  smoke,  carbon  monoxide  and 
illuminating  gas,  nitrous  fumes  and  other  toxic  vapors  from  acids,  chemicals, 
celluloid,  benzine,  turpentine,  etc.  .  Cases  of  asphyxia,  pulmonary  oedema 
and  pneumonia  are  not  uncommon.  Accidents  and  electric  shocks,  are  also 
quite  frequent.  The  fatal  accident  rates  of  the  chiefs  of  batallion  in  the 
New  York  City  fire  department  between  1902-1911  according  to  Hoffman,* 
was  8.4  per  1000  and  that  of  the  firemen  2.4  per  1000,  The  men  employed 
on  the  police  force  are  engaged  in  out-door  work  and  the  duties  are  not  unUke 
those  of  soldiers  in  time  of  peace.  The  chief  occupational  risks  are  exposure 
to  inclement  weather,  long  hours,  irregular  sleep  and  meals. 

The  following  comparative  mortality  statistics  are  compiled  from  data 
furnished  by  Hoffman : 


Principal  causes  of  deaths 

New  York  Fire  Dept.  1902- 

1911,  force  exposed  per  annum 

37,526,  rate  per  10,000 

Chicago  Police  Force  igoi-ipio, 

force  exposed  per  annum  34.087, 

rate  per  10,000 

Accidents 

23.2 
9-3 
6.9 
5-3 
4.8 

3-7 

17.6 

Pneumonia     

iS-5 

Tuberculosis 

12.9 

Urinary  diseases 

lO.O 

Heart  diseases 

147 

Digestive  diseases 

6.S 

The  mortaUty  rates  from  pneumonia  and  tuberculosis  in  the  Chicago 
police  force  are  especially  excessive,  which  is  doubtless  due  to  climatic  and 
racial  conditions  in  that  city. 


7o8        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

Stationary  Firemen  and  Engineers.— The  men  employed  in  power  plants, 
notably  the  firemen,  coal  heavers  and  laborers,  are  exposed  to  excessive 
heat  and  sudden  changes  in  temperature,  especially  when  the  workmen  step 
out-doors  to  cool  off.  There  is  also  more  or  less  exposure  to  dust  from  ashes 
and  coal,  and  escaping  gases  and  steam.  The  work,  unless  automatic 
stokers  are  employed,  is  fatiguing  and  is  often  carried  on  in  dark,  damp  and 
dirty  quarters.  The  mortahty  from  tuberculosis  is  about  ii  per  cent,  and 
the  accident  rate  about  12  per  cent. 

The  men  engaged  in  attending  furnaces  in  connection  with  foundry 
work,  kilns  and  drying  rooms,  enamelling,  japanning,  baking  ovens,  etc., 
are  exposed  to  similar  occupational  risks.  In  some  industries  there  is  an 
added  danger  from  poisonous  dust  and  fumes,  and  exposure  to  intense  heat 
and  light. 

Working  conditions  should  be  improved  by  adequate  exhaust  fans, 
movable  screens,  mechanical  contrivances,  eye  protection  against  intense 
heat,  light  and  foreign  bodies.  Shower  baths  and  facilities  for  personal 
cleanliness  are  essential. 

Commercial  and  Mercantile  Pursuits. — There  are  two  groups  of  em- 
ployees in  commercial  pursuits  which  deserve  consideration.  The  first 
group,  according  to  Chajes,^  includes  the  office  employees,  bookkeepers, 
cashiers,  stenographers,  typists,  travelling  salesmen,  clerks,  stockclerks, 
floor  walkers,  etc. ;  the  second  group  includes  porters,  shipping  clerks,  delivery 
wagon  drivers,  messengers,  laborers,  etc. 

The  German  Insurance  statistics  from- 1903-1905  show  that  of  215,981 
male  employees  there  were  76,334  cases  of  illness  or  35.38  per  cent,  per  annum. 
Of  114,824  female  employees  there  were  48,733  cases  of  illness,  i.e.,  or  42.44 
per  cent.  The  average  for  both  sexes  was  38.8  per  cent,  which  is  about  3 
per  cent,  higher  than  the  general  average  in  other  occupations.  The  preva- 
lent diseases  among  the  male  employees  were  diseases  of  the  respiratory  and 
digestive  organs  and  diseases  of  the  nervous  system.  Among  the  female 
employees,  anaemia  and  chlorosis  came  first  with  a  morbidity  rate  of  30  per 
cent.;  next  diseases  of  the  respiratory  and  of  digestive  organs;  followed  by 
diseases  of  the  nervous  system.  About  29.5  per  cent,  of  those  reported 
sick  had  sustained  accidents,  which  are  especially  common  among  the 
porters  and  packers  and  in  the  stock  and  shipping  departments.  Near- 
sight,  caused  by  defective  lighting,  and  deformities  of  the  knee,  "flat-foot," 
and  varicose  veins  are  not  uncommon. 

About  19  per  cent,  of  the  morbidity  among  the  office  and  store  force  was 
due  to  diseases  of  the  lungs;  the  percentage  among  the  porters,  packers,  etc., 
was  betwen  21  and  29,  probably  on  account  of  additional  exposure  to  dust; 
41  per  cent,  of  all  the  deaths  were  caused  by  tuberculosis.  Among  the 
diseases  of  the  digestive  organs  with  a  morbidity  rate  of  7-xi  per  cent., 
gastric  and  intestinal  catarrh,  chronic  constipation,  gastric  ulcer,  and 
hemorrhoids  were  the  most  frequent.     Rheumatism,  anaemia,  neurasthenia 


PUBLIC  SERVICES,  TELEPHONE  ANT)  TELEGRAPH  OPERATORS    709 

and  other  nervous  afifections  are  not  uncommon.  Occupation  neuroses  are 
occasionally  observed  in  stenographers  and  typists. 

Travelling  salesmen  often  contract  the  alcohol  habit.  Peddlers  and 
small  shopkeepers  have  a  very  high  tuberculosis  death  rate  in  Bavaria,  8 
per  1000  against  3.07  in  the  occupied  male  population  (Koelsch).® 

The  long  hours,  indoor  life,  exposure  to  vitiated  air,  uneven  temperature, 
drafts  and  sedentary  habits  in  the  office  force  naturally  favor  the  develop- 
ment of  pulmonary  disorders.  These  same  factors,  together  with  the  mental 
strain  in  accountants,  t3'pists  and  stenographers,  also  predispose  to  anaemia, 
chlorosis,  malnutrition  and  diseases  of  the  nervous  s^vstem.  Cold  lunches, 
improper  food,  hasty  eating,  sedentary  or  standing  habits  and  many  of  the 
conditions  incident  to  indoor  occupations,  are  doubtless  responsible  for  the 
undue  prevalence  of  diseases  of  the  digestive  organs. 

Preventive  Measures. — Commendable  progress  has  been  made  in  the 
sanitation  of  mercantile  establishments,  but  much  more  needs  to  be  done 
in  the  way  of  ventilation,  heating,  lighting  and  general  cleanhness.  All 
sweeping  and  dusting  should  be  done  b}^  the  vacuum  system.  Vestibule 
doors  should  be  provided  in  winter  to  avoid  cold  drafts.  The  law  makes 
provisions  for  seats  for  female  clerks  and  they  should  be  encouraged  to 
use  them. 

Stores  should  not  be  open  for  over  9  hours  a  day  with  i  hour  for  lunch 
and  rest.  Large  establishments  should  provide  rest  rooms  and  hot  lunches 
at  reasonable  prices.  Female  employees  deserve  special  consideration; 
they  are  usually  underpaid,  and  as  a  result  the  home  environments  are  not 
conducive  to  health. 

Telephone  and  Telegraph  Service. — The  telephone  service  is  rapidly 
growing  and  is  of  special  interest  because  it  affords  employment  to  a  large 
number  of  females.  The  occupation  involves  indoor  life,  concentration 
and  alertness  of  mind,  and  many  vexations  which  cannot  fail  to  exert  an 
injurious  effect  upon  the  operators. 

Statistical  data  is  still  lacking,  but  general  observation  indicates  that 
the  switchboard  service  predisposes  to  the  development  of  neurasthenia 
and  hysteria.  Opinions  as  to  the  effect  of  the  occupation  upon  hearing  differ 
very  widelv;  some  authors  hold  that  it  leads  to  impairment,  while  others 
contend  that  the  sense  of  hearing  is  rendered  more  acute. 

A  few  cases  of  paralysis  of  the  vocal  chords  have  been  reported  and  at- 
tributed to  the  excessive  use  of  the  voice  and  constrained  position  in  tele- 
phoning. A  more  important  group  of  injuries  is  caused  by  sudden  and  violent 
acoustic  effects  upon  the  auditory  nerve  of  the  person  using  the  receiver. 
This  phenomena  may  be  caused  by  entrance  of  a  high-tension  current  into  the 
telephone  circuit,  by  breakage  of  a  power  or  light  cable,  or  during  an  electric 
storm.  According  to  Bernhardt^  in  some  instances  these  violent  acoustic 
bangs  have  produced  rupture  of  the  ear-drum.  This  accident  must  be  very 
rare,  however,  as  I  have  been  unable  to  find  similar  cases  in  the  literature. 


7IO        ETIOLOGY   AND   PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

In  the  majority  of  cases,  a  slight  shock  from  low  voltage  simply  produces  a 
psychic  shock  and  the  frightened  operators  sometimes  become  quite  hysterical. 

M.  Capart's^  extended  experience  leads  him  to  conclude  that  the  normal 
operations  of  the  telephone  produce  no  injurious  effects.  But  abnormal 
acoustic  effects  are  very  liable  to  develop  profound  symptoms  of  hysteria 
and  aggravate  chronic  affections  of  the  ear.  The  presence  of  impacted 
ear  wax  was  found  by  Castaneda^  to  be  the  cause  of  frequent  attacks  of  nausea 
and  dizziness  in  a  telephone  operator.  Koelsch^"  informs  us  that  in  Germany 
during  the  year  1907,  eight  telephone  operators  were  injured  by  the  trans- 
mission of  high-tension  currents,  seven  by  the  induced  current,  and  two 
others  by  the  effects  of  lightening. 

In  the  Chicago  Telephone  Co.,  according  to  Dr.  J.  D.  McGowan,^^  there 
were  in  i  vear  473  cases  of  shock  reported,  two  of  which  resulted  in  death. 
Most  of  the  serious  cases  occurred  in  linemen. 

Dr.  McGowan  also  refers  to  the  accidents  liable  to  befall  linemen,  such 
as  fractures,  dislocations,  sprains,  wounds,  contusions,  and  nail  punctures, 
and  the  frequency  of  septic  infections  of  wounds,  caused  by  copper  wire.  It 
is  diflScult  to  conceive  why  copper  or  verdigris,  which  is  so  much  feared  by 
the  workmen  both  here  and  abroad,  should  be  held  responsible  for  septic 
conditions  of  wounds  which  are  of  bacterial  origin.  This  class  of  employees 
is  especially  liable  to  electric  shock,  burns  and  other  injuries  from  crossed 
wires,  etc.,  which  have  been  considered  in  another  chapter,  see  page  402. 
Hoffman's  statistics  based  upon  205  deaths  among  electric  linemen  show 
a  mortahty  of  48.3  per  cent,  from  accidents  18.5  per  cent,  from  tuberculosis, 
6.3  per  cent,  from  other  lung  diseases,  6.3  per  cent,  from  heart  disease,  3.9 
per  cent,  from  digestive  diseases,  3.4  per  cent,  from  urinary  diseases.  Workers 
in  cable  vaults  are  also  often  exposed  to  gas  poisoning.      (See  page  416.) 

The  occupation  of  telegraphers  involves  many  of  the  risks  already  referred 
to,  except  that  the  telegraph  operators,  as  a  result  of  over-exercise  of  certain 
groups  of  muscles,  are  liable  to  develop  a  fatigue  neurosis  of  the  muscles 
of  the  hand  and  forearm,  which  is  analogous  to  "writers'  cramp." 

Preventive  Measures. — There  is  no  doubt  that  the  occupation  of  both 
telephone  and  telegraph  operators  involves  a  severe  strain  upon  the  nervous 
system,  which  can  be  greatly  mitigated  by  favorable  working  conditions, 
shorter  working  hours,  and  by  kind  and  considerate  treatment  on  the  part 
of  the  general  public.  The  female  operators,  because  of  the  strenuous  char- 
acter of  the  work,  are  entitled  to  special  protection  and  should  not  be  obliged 
to  work  over  8  hours  out  of  the  24,  with  reasonable  intervals  for  rest,  which 
should  be  taken  in  cheerful,  airy  and  comfortable  rest  rooms. 

In  the  matter  of  accident  prevention,  Dr.  McGowan  states  that,  while 
shocks  are  common,  severe  shocks  causing  deaths  are  now  rare  in  com- 
parison to  what  they  were  10  years  ago,  owing  to  the  various  safety 
devices,  the  greater  care  in  supervision  and  greater  caution  on  the  part  of 
the  employee. 


ELEVATOR    AND    RAILWAY    SERVICE.  71I 

The  large  number  of  accidents  from  electric  shock  in  Chicago,  as  com- 
pared with  the  German  statistics,  shows  that  more  remains  to  be  done  to 
prevent  the  transmission  of  high-tension  currents  by  the  abolition  of  overhead 
wires,  and  the  general  introduction  of  safety  devices  for  the  prevention  of  the 
entrance  of  strong  currents  of  atmospheric  electricity. 

Operators  and  all  others  using  the  long  distance  wires  during  electric 
Storms  should  handle  the  receiver  with  a  silk  glove  or  handkerchief.  Ex- 
cellent safety  devices  have  been  introduced  for  the  prevention  of  slight  shocks 
from  a  low  voltage,  caused  by  the  old-time  method  of  violent  ringing. 

The  majority  of  telephone  operators  in  the  central  station  in  the  City  of 
Washington  are  females;  they  are  on  duty  for  9  out  of  24  hours,  with  i 
hour  for  complete  rest,  and  intermissions  of  10  minutes  after  2  hours  of  work. 

The  company  has  provided  rest  rooms,  lunch  rooms  and  an  emergency 
room.  The  working  conditions  are  favorable,  and  all  vexatious  patrons 
are  promptly  switched  over  to  a  calm  and  tactful  operator,  who  adjusts  the 
difficulties  and  thus  spares  both  parties  from  a  nervous  strain. 

Elevator  Employees. — A  large  number  of  persons  are  employed  as  ele- 
vator conductors.  The  accident  liability  in  this  occupation  is  by  no  means 
insignificant  and  numerous  fatal  injuries,  the  result  of  carelessness  or  direct 
violation  of  rules,  such  as  open  doors  or  sudden  starting,  are  constantly 
recorded. 

Among  the  non-fatal  injuries  may  be  mentioned  fractures  of  the  lower 
extremities,  pelvic  bones  and  spine,  the  result  of  falls  through  an  open  door 
down  the  elevator  shaft,  while  crushing  injuries  of  the  foot  are  not  infre- 
quently caused  by  being  caught  in  starting  between  the  door  and  shaft. 
Fatal  injuries  and  contusions  of  the  chest  often  result  from  carelessness  dur- 
ing the  oiling  or  inspection  of  the  running  gear,  and  the  head  injuries  are 
usually  caused  by  falling  objects  from  above.  Minor  injuries,  such  as  con- 
tusions and  fractures  of  fingers  or  bones  of  the  hand,  may  result  from  being 
caught  between  the  doors  in  the  attempt  to  close  them.  Lacerations  of  the 
hand  may  occur  as  a  result  of  a  slipping  wire  rope,  which  is  also  the  cause  of 
painful  callosities  and  contracted  tendons  in  the  palm  of  the  hand. 

"Flat-foot"  and  varicose  veins,  the  result  of  prolonged  standing,  and 
catarrhal,  rheumatic  and  neuralgic  affections,  caused  by  drafts  and  uneven 
temperature,  are  frequently  observed. 

Preventive  Measures. — Reasonable  working  hours  and  strict  enforce- 
ment of  the  rules  governing  the  elevator  service. 

Railway  Service. — The  employees  in  the  railway  service,  apart  from  Ua- 
bility  to  accidents,  lead  a  life  full  of  responsibility  and  hardships.  This, 
together  with  irregular  habits  as  regards  work;  sleep  and  meals,  and  exposure 
to  dust,  drafts,  etc.,  increases  their  liability  to  sickness  in  spite  of  the  fact 
that  generally  only  able-bodied  men  are  employed. 

According  to  RudHn^^  of  280,098  employees  in  the  Prussian-Hessian 
system  in  1905,  the  morbidity  rate  was  41.97  per  cent,  with  an  average  dura- 


712        ETIOLOGY   AND   PROPHYLAXIS    OF    OCCUPATIONAL  DISEASES 

tion  of  26.69  days.  The  German  statistics  prior  to  1890  show  a  morbidity 
rate  of  48  per  cent.  The  train  hands,  dispatchers,  switchmen,  track  walkers 
and  gatemen  show  the  greatest  amount  of  sickness  and  the  station  and  office 
force  the  least.  Diseases  of  the  digestive  organs,  diseases  of  the  respira- 
tory system,  rheumatism  and  diseases  of  the  nervous  system  appear  to 
predominate. 

Schwechten^^  reports  a  notable  decrease  in  the  tuberculosis  death  rate, 
which  has  decUned  from  34.8  per  10,000  of  employees  in  1878-82  to  16.3 
per  10,000,  a  reduction  of  53  per  cent.  While  organic  diseases  of  the  nervous 
system,  railway  spine,  insanity  and  apoplexy  have  decreased,  an  increase 
in  functional  disorders,  such  as  neurasthenia,  hysteria,  etc.,  is  noted. 

The  undue  prevalence  of  rheumatic,  catarrhal  and  neuralgic  affections  is 
probably  accounted  for  by  sudden  changes  in  temperature  to  which  train 
hands  are  especially  exposed  during  the  cold  months. 

Dr.  EdsalP^  upon  the  authority  of  Dr.  Latta,  Railway  Surgeon  of  the 
Penna.  R.  R.  Co.,  calls  attention  to  the  frequency  of  right-sided  cases  of 
sciatica  in  locomotive  engineers.  This  was  traced  to  the  fact  that  some  of 
the  men  are  in  the  habit  of  sitting  sidewise  on  the  bench  of  the  right-hand  side 
of  the  engine  cab  and,  in  the  constant  jolting,  the  weight  of  the  body  is  con- 
tinually thrown  violently  on  the  right  thigh  and  buttock.  The  number  of 
cases  was  reduced'and  the  special  tendency  to  right-sided  cases  eliminated 
by  simply  cutting  off  the  forward  part  of  the  bench,  so  that  the  engineer 
had  to  sit  squarely  facing  forward. 

Disorders  of  the  digestive  system  are  doubtless  influenced  by  irregular 
meal  hours,  and  the  character  of  food  and  drinks.  Iced  or  very  cold  drinks 
are  especially  harmful,  and  since  the  months  of  July  and  August  furnish  the 
greatest  number  of  cases  of  gastric  catarrh,  this  causative  factor  may  at  least 
be  assumed. 

Hedinger^^  called  attention  to  the  fact  that  only  8  per  cent,  of  the  German 
locomotive  engineers  have  normal  hearing,  while  67  per  cent,  of  the  engineers 
and  30  per  cent,  of  the  firemen,  and  14.5  per  cent,  of  the  track  walkers  had 
defective  hearing.  The  percentage  in  all  increased  with  the  length  of 
service.  The  most  common  affection  was  catarrh  of  the  Eustachian  tube, 
and  internal  ear,  probably  caused  by  frequent  exposure  to  abrupt  changes 
in  temperature. 

Hoffman's^^  statistics  based  upon  537  deaths  among  brakemen  show  a 
mortahty  from  accidents  of  63.3  per  cent,  from  tuberculosis  11.9  per  cent., 
pneumonia  3.2  per  cent.,  digestive  diseases  3  per  cent.,  heart  disease  2.6 
per  cent.,  nervous  diseases  2  per  cent.,  apoplexy  and  paralysis  1.5  per 
cent. 

Railway  Accidents. — The  fatal  accidents  to  railway  employees  have 
been  gradually  reduced  from  9.52  per  1000  in  1890  to  4.78  per  1000  in 
1909.  The  following  table  compiled  by  the  Prudential  Insurance  Com- 
pany of  America  is  of  special  interest. 


RAILWAY    SERVICE. 


713 


Causes  of  Fatal  Accidents  to  Trainmen,  1901-1909 
(Employees  exposed  i  year  2,363,077) 


Cause 


Total  accidents 


Rate  per  10,000 


Falls  from  trains 

Collisions 

Struck  by  trains 

Derailments 

Coupling  or  uncoupling 

Other  movements  of  trains. . . 

Jumping  on  or  off 

Overhead  obstructions 

Breaking  do\\Ti  of  equipment. 
Parting  of  trains 


3710    1 

iS-7 

3202 

13-6 

3104 

13  I 

1974 

8.4 

1874 

7-9 

1624 

6.9 

943 

4.0 

634 

2.7 

199 

0.8 

154 

0.7 

Summary  of  Accidents   Resulting  from  Collisions  and  Derailments  for  the  10 

Years  Ended  June  30,  19 13* 


Year 


Number 


Persons 


Killed 


Injured 


Damage   to   road 

and  equipment,  and 

cost  of  clearing 

wrecks 


1904. 

1905- 
1906. 
1907. 
1908. 
1909. 
I910. 
1911. 
1912. 
1913- 


11,291 

11,595 
13,455 
15,458 
13.034 
9,670 

11,779 
11,865 
13,698 

15-526 


1,018 

1,064 

977 
1,291 

728 
606 
773 
785 
772 

791 


10,244 
11,949 
12,686 
16,236 
12,834 
9,560 
12,579 
11,793 
15,096 

14,565 


59,383,077 

9,711,656 

10,659,189 

12,865,702 

10,183,660 

7,480,203 

9,823,958 

9,851,780 

11,527,458 

13,049,214 


Preventive  Measures. — Every  effort  which  will  promote  the  health  and 
comfort  of  passengers  in  the  way  of  temperature,  ventilation,  light  and 
mitigation  of  the  dust  evil,  cannot  fail  to  prove  beneficial  to  a  large  number 
of  employees.  The  sanitation  of  passenger  coaches  is  still  defective,  in  the 
matter  of  cleaning,  which  should  be  done  more  frequently  and  thoroughly. 
The  vacuum  system  is  especially  indicated  for  upholstery.  Leather  or  some 
impermeable  material  should  replace  plush  covers.  The  temperature  in  cars 
during  the  cold  months  should  be  maintained  between  70°  and  75°. 

It  is  generally  conceded  that  safety  in  railroad  operation  is  the  result  of: 
(i)  Properly  constructed  and  maintained  track  signals  and  rolling  stock. 
(2)  Careful  rules  and  regulations.     (3)  Carefully  selected  and  trained  em- 

*  Figures  for  number  of  persons  killed  and  injured  for  years  prior  to  19 11  are  restricted 
to  passengers  and  employees  on  duty.  (27th  Annual  Report  of  the  Interstate  Commerce 
Commission,  Washington,  D.  C.  1913) 


714        ETIOLOGY   AND   PROPHYL.^XIS    OF   OCCUPATIONAL   DISEASES 

ployees,  of  sober  habits,  who  faithfully  discharge  their  duties.  (4)  Intelli- 
gent and  comprehensive  supervision. 

These  cardinal  principles  are  carried  out  by  the  management  of  the  Penn- 
sylvania Railroad  Lines,  with  the  result  of  having  the  best  record  in  accident 
prevention  in  191 2.  The  Company  maintains  its  rolHng  stock  with  a  large 
percentage  of  steel  cars  in  a  high  state  of  efficiency  and  has  introduced  safety 
devices  in  the  shops  and  roundhouses  where  over  41,000  men  are  employed. 
In  1911  the  Company  appointed  35  safety  committees  who  made  17,333 
formal  recommendations,  of  which  13,861  were  acted  upon,  one  of  the  results 
being  that  by  the  expenditure  of  $99,753  for  safety  guards,  mainly  in  shops, 
the  serious  accidents  to  shop  employees  have  been  reduced  from  5.4  per  1000 
to  3.2  in  1912.  The  Company  maintains  105  hospitals,  and  employs  an 
efl5cient  medical  corps  not  only  for  emergency  and  hospital  work,  but  also 
for  the  instruction  of  all  employees  in  first  aid.  During  the  year  ended 
August  31,  1913,  195  lectures  and  demonstrations  were  given,  particularly 
at  the  larger  shops.  All  stations,  shops,  engine  cabs,  cabin  cars,  etc.,  are 
equipped  vnth.  "first-aid"  kits. 

Street  Railway  Employees. — The  hygiene  of  this  occupation  does  not 
materially  differ  from  that  of  the  general  railway  service.  The  working  hours 
of  the  traffic  fqrce  are  unusually  long,  the  shifts  are  irregular  and  involve 
both  night  and  day  work. 

Professor  Weyl,^^  with  his  characteristic  thoroughness,  presents  statistical 
data  bearing  upon  the  accident  and  morbidity  liability  of  this  class  of  workers 
in  Germany. 

In  1905  there  were  reported  among  60,940  employees  4253  accidents  or 
a  rate  of  69.73  pc^  i°°°  full-time  workers.  Of  this  number  31  proved  fatal, 
35  resulted  in  permanent  total  disabiHty,  293  in  partial  permanent  disability, 
and  104  in  temporary  disability.  A  majority  of  the  serious  injuries  were 
caused  by  falls  and  being  run  over. 

The  inspectors  and  overseers  of  the  traffic  lines  furnished  the  largest 
percentage;  next  came  the  employees  in  the  mechanical  department,  followed 
by  the  motor  men  and  conductors.  The  same  relative  frequency  was  noted 
in  the  morbidity  rates,  except  that  the  "extra  force,"  which  is  made  up  of 
inexperienced  men,  furnish  the  highest  rates. 

The  morbidity  statistics,'  which  are  based  on  a  membership  of  8523, 
show  that  there  were  6471  cases  of  sickness  with  88,149  days'  loss  of.  work. 
Colds,  influenza,  tonsillitis  and  rheumatism  were  the  cause  of  illness  in  241 1 
cases;  digestive  disorders  furnished  1248  cases,  diseases  of  the  respiratory 
system,  inclusive  of  consumption,  611.  The  mortality  rate  from  consump- 
tion, which  was  especially  high  in  the  oflSice  and  temporary  force,  was  22.6 
per  cent.  There  were  also  265  cases  of  mental  and  nervous  diseases;  376 
cases  of  skin  diseases;  222  cases  of  ear,  nose  and  throat  affections;  161  cases 
of  diseases  of  the  eye;  89  cases  of  heart  disease;  and  54  cases  of  varicose  veins; 
cases  of    flat-foot,"  hernia  and  frost-bite  are  not  uncommon. 


SUBWAY   EMPLOYEES.  715 

In  view  of  the  fact  that  the  employees  are  primarily  picked  men,  the  mor- 
bidity rates  appear  to  indicate  that  the  same  injurious  factors  pointed  out 
in  connection  with  the  general  railway  service  also  operate  in  this  branch. 

Dr.  Schwarze^^  emphasizes  the  strain  upon  the  eyes  and  ears,  the  develop- 
ment of  "flat-foot"  and  varicose  veins  from  prolonged  standing  and  the  un- 
due prevalence  of  chronic  conjunctivitis,  from  exposure  to  dust  and  drafts 
as  incident  to  the  occupation.  While  the  occupation  predisposes  to  nervous 
affections,  the  real  cause  of  neurasthenia  is  often  not  at  all  connected  with 
the  service.  Motormen  who  almost  constantly  stamp  on  the  gong  pedal 
often  develop  neuroses  of  the  right  leg.  Schwarze  refers  to  occasional  cases 
of  burns  from  the  electric  current,  and  to  the  comparative  rarity  of  injuries 
from  electric  shock,  having  observed  but  one  case  during  10  years.  As  causes 
of  hernia  he  mentions  the  faulty  position  of  the  motormen  in  the  use  of  the 
brake,  and  the  habit  of  the  conductors  in  leaning  too  far  back  over  the  rear 
platform,  to  which  may  be  added  the  muscular  strain  involved  in  jumping 
on  and  off  the  cars. 

Preventive  Measures. — While  it  cannot  be  said  that  this  occupation  is 
intrinsically  dangerous  to  health,  much  could  be  done  to  diminish  exposure 
to  the  elements  and  dust  by  inclosed  platforms.  Adjustable  seats  for  the 
motorman  should  be  provided.  The  clothing  should  be  adapted  to  climate 
and  seasons.  The  establishment  of  reasonable  working  hours,  and  of 
lunch  rooms,  where  hot  soups,  coffee,  tea,  etc.,  are  served,  would  do  much  to- 
ward the  prevention  of  the  alcohol  habit  and  of  accidents. 

Subway  Employees. — We  have  as  yet  no  statistical  data  to  justify  posi- 
tive conclusions  as  to  the  injurious  effects  of  employment  in  the  subway 
service.  Dr.  Sutherland  determined  that  the  proportion  of  carbon  dioxide 
in  the  air  of  subway  stations  and  cars  varies  from  4  to  20  parts  per  10,000 
volumes  as  compared  with  2.8  in  the  outer  air. 

Dr.  G.  A.  Soper^^  of  New  York  has  shown  that  the  subway  dust  con- 
tains 61.3  per  cent,  of  iron,  mostly  in  the  form  of  fine  platelets;  21.9  per  cent, 
of  organic  matter  of  animal  and  vegetable  origin;  i5.6per  cent,  mineral  matter, 
mostly  silica;  and  1.3  per  cent,  of  oily  matter. 

The  average  amount  of  dust  was  61.6  mg.  and  the  maximum  weight  was 
204  mg.  per  1000  cubic  meters  of  air.  The  excess  of  dust  in  the  subway  air 
over  the  outer  air  averaged  47  per  cent.  Dr.  Soper  found  that  magnets  hung 
up  in  the  subway,  collected  more  particles  of  iron  than  magnets  of  the  same 
size  and  strength  hung  up  in  an  iron  foundry  or  in  a  dry  grinding  and  polish- 
ing establishment.  From  samples  taken  it  was  estimated  that  in  every 
month  25  tons  of  iron  and  steel  are  ground  off  the  rails,  brake- shoes  and  wheels 
on  the  21  miles  of  subway.  The  greatest  wear  and  tear  falls  upon  the  cast- 
iron  shoes  of  the  powerful  brakes,  amounting  to  i  ton  per  mile  a  month. 

The  physical  examination  of  the  men^"  revealed  an  excessive  amount  of 
dry  pleurisy  without  pain  or  other  physical  discomfort,  the  proportion  being 
53  per  cent,  against  14.5  per  cent,  among  men  not  engaged  in  subway  work. 


7l6        ETIOLOGY   AND   PR0PHYL.4XIS    OF   OCCUPATIONAL   DISEASES 

Congestion  and  inflammation  of  the  upper  air  passages  were  also  prevalent. 
The  drafts  and  changes  of  temperature  at  or  near  the  stations  and  the 
character  of  dust  are  doubtless  injurious  factors. 

Preventive  Measures. — It  is  reasonable  to  assume  that  the  factors  men- 
tioned are  inimical  to  the  health  of  employees,  who  are  exposed  for  several 
hours  daily  to  the  inhalation  of  dust,  which  is  known  to  produce  structural 
changes  in  the  lungs.  No  effort  should  be  spared  to  reduce  dust  production 
and  to  mitigate  its  effects  by  ventilation  and  copious  oiling  of  the  roadbeds. 

Automobilists. — -The  hygiene  of  automobilists  is  still  in  its  infancy  and 
we  have  no  statistical  data  to  justify  positive  conclusions  as  to  the  influence 
of  exposure  to  fine  road  dust,  smoke,  and  other  products  of  gasoline  com- 
bustion upon  the  habitual  users  of  automobiles.  Dr.  Delavan^^  has  pointed 
out  that  dust  and  smoke,  temperature,  air  pressure  and  winds  are  fruitful 
causes  of  inflammatory  conditions  of  the  nasal  cavities,  pharynx,  larynx, 
trachea,  bronchi  and  lungs.  It  can  be  readily  understood  how  these  causative 
factors  are  intensified  during  speeding,  since  a  speed  of  30  miles  will  create, 
even  in  a  calm  atmosphere,  currents  equivalent  to  a  stiff  breeze.  This 
alone  is  calculated,  especially  in  cold  weather,  to  abstract  an  undue  amount  of 
animal  heat  and  prediposes  to  congestions  of' the  internal  organs,  while  dust 
and  fumes  will  serve  to  aggravate  the  evil  effects. 

Cases  of  gasoline  poisoning  have  been  reported  by  Dr.  Box,^^  in  chaffeurs 
who  were  maneuvering  a  motor  car  in  a  closed  garage.  Similar  cases  are 
mentioned  by  Oliver^^  and  also  cases  of  carbon  monoxide  poisoning,  from  de- 
fective exhaust  pipes. 

Affections  of  the  eyes  and  skin,  caused  by  exposure  to  the  sun  and  dust, 
are  not  infrequent.  Sciatica,  neuralgia,  muscular  rheumatism  and  numb- 
ness in  the  lower  extremities  are  prevalent,  and  attacks  of  pseudo-angina  have 
been  observed  after  violent  efforts  in  cranking.  Constant  and  excessive 
pressure  with  the  right  foot  has  been  known  to  produce  sciatica  and  lum- 
bago. It  is  highly  probable  that  the  nervous  strain,  combined  with  constant 
and  rapid  concussions,  tends  to  produce  similar  diseases  of  the  nervous 
system  as  are  observed  in  locomotive  engineers. 

Borattaue^^  mentions  that  injurious  effects  are  produced  in  all  per- 
sons suffering  from  diseases  of  the  respiratory,  circulatory  and  female  genital 
organs;  and  Paul  le  Gendre^^  reports  cases  of  sudden  death  in  chaffeurs  from 
heart  lesions.  The  liability  to  accidents  from  colHsions  and  otherwise  is 
also  very  considerable  in  this  age  of  speed.  Colles's  fracture  the  result  of 
back  fire  is  notoriously  common. 

Preventive  Measures.— T)\xsi\ts?,  streets  and  roads,  rules  limiting  the 
speed  to  12  miles  or  less  per  hour  in  cities,  and  to  20  miles  on  country  roads, 
careful  trafl5c  rules  in  cities,  proper  clothing  and  protection  of  the  eyes  by 
suitable  glasses,  wind  shields,  and  the  habit  of  breathing  through  the  nose, 
are  also  important  safeguards,  while  automatic  sparking  blocks  will  diminish 
the  number  of  Colle's  fractures. 


DRAYMEN,    HACKMEN,    ETC.  717 

Draymen,  Hackmen,  and  Teamsters.— During  the  census  year  of  iqoo 
the  number  of  drivers  and  teamsters  in  the  U.  S.  was  532,632;  the  mortality 
rate  from  consumption  was  2.6  per  1000,  and  the  death  rate  from  other  dis- 
eases of  the  lungs  was  1.7  per  1000.     (See  also  page  753.) 

The  industrial  insurance  statistics  cited  by  Hoffman"  include  3850 
deaths,  of  which  999  or  25.9  per  cent,  were  caused  by  consumption,  483 
or  12.5  per  cent,  from  pneumonia,  56  or  1.5  per  cent,  from  bronchitis  and  93 
or  2.4  per  cent,  from  other  diseases  of  the  lungs  making  a  combined  death 
rate  of  42.4  per  cent,  from  diseases  of  the  respiratory  organs,  against  an  ex- 
pected rate  of  26.5  per  cent. 

The  mortality  rate  from  diseases  of  the  heart  and  arteries  was  also 
excessive.  While  exposure  to  road  and  municipal  dust,  inclement  weather, 
and  hard  work,  especially  in  the  draymen  and  teamsters,  are  doubtless 
important  predisposing  factors,  the  effects  of  the  alcohol  habit  cannot  be 
ignored. 

The  death  rate  from  accidents  and  injuries  in  this  class  of  employees  in 
1900  was  1.33  per  1000.  Only  six  of  the  other  27  occupations  tabulated  fur- 
nished a  higher  rate. 

Preventive  Measures — -The  undue  prevalence  of  diseases  of  the  re- 
spiratory organs  plainly  indicates  that  dust  plays  an  important  role;  hence  no 
effort  should  be  spared  to  reduce  the  amount  of  road  and  street  dust,  pri- 
marily by  proper  construction  of  the  highways  and  next  by  frequent  cleaning 
of  streets  and  oiling  of  roads. 

Street  Cleaners,  Ice,  Coal  and  Ash  Men  and  General  Day  Laborers. — 
Although  these  occupations  are  carried  on  largely  in  the  open  air,  foreign 
statistics  show  that  this  group  is  subject  to  the  highest  morbidity  and  mor- 
tality rates,  especially  from  diseases  of  the  respiratory  organs.  The  accident 
rate  is  also  excessive,  and  diseases  of  the  heart  and  arteries  as  a  result  of  hard 
work  are  likewise  quite  common. 

The  dirty  character  of  the  work  predisposes  to  diseases  of  the  skin  and 
septic  infections.  Rheumatism  as  a  result  of  exposure  to  the  elements  is 
not  infrequent,  and  the  undue  prevalence  of  diseases  of  the  digestive  system 
is  doubtless  influenced  by  the  scale  of  wages  and  character  of  'food.  Our 
American  statistics  are  limited  to  street  cleaners  and  the  evidence  gathered 
by  Hoffman^^  from  Medical  Journals  indicates  that  about  one-third  of  the 
5000  street  cleaners,  in  1907,  in  New  York,  were  infected  with  tuberculosis, 
in  spite  of  the  fact  that  these  men,  previous  to  employment,  were  examined 
by  Civil  Service  Surgeons  and  pronounced  free  from  organic  disease.  The 
men  employed  on  the  East  side,  where  the  streets  are  in  a  more  filthy  con- 
dition, suffered  more  from  diseases  of  the  nose,  throat  and  lungs,  than  the 
sweepers  of  the  West  side. 

The  more  accurate  data  furnished  by  Hoffman"  are  based  upon  the 
industrial  insurance  statistics,  which  deals  with  180  deaths  among  street 
cleaners;  of  this  number  33  or  18.3  per  cent,  died  from  consumption,  and 


7l8        ETIOLOGY   AND   PROPHYLAXIS    OF   OCCUPATIONAL   DISEASES 

a  like  number  perished  from  pneumonia  and  other  diseases  of  the  lungs, 
making  a  combined  mortality  rate  of  36.7  per  cent,  from  diseases  of  the 
respiratory  organs.  The  Bavarian  statistics  cited  by  Koelsch^^  show  that 
the  tuberculosis  death  rate  in  this  group  of  employees  is  83.1  per  1000  living, 
or  27  times  higher  than  in  the  average  occupied  male  population.  In  Eng- 
land it  is  5-6  times  higher.  On  the  other  hand,  we  have  the  studies  of  Augustus 
Gay,  cited  by  Edsall,^^  on  nightmen,  scavengers  and  dust  men  showing  that 
they  presented  an  unusually  good  average  health.  The  observations  made 
in  the  so-called  dust  women  of  London,  who  are  engaged  in  picking  from  the 
city  refuse  such  articles  as  rags,  twine,  paper,  old  leather  and  rubber,  bones, 
coal,  cork,  broken  glass,  etc.,  led  Oliver^"  to  conclude  that,  in  spite  of  the 
extremely  dusty  character  of  the  work,  the  women  become  apparently  immune 
to  its  possible  evil  effects — all  of  which  indicates  that  more  intensive  studies 
are  needed.  Kryz*^  has  recently  called  attention  to  the  sharp,  angular  and 
irritant  character  of  dust  from  ashes. 

It  is  difl&cult  to  determine  how  much  social  economic  factors  have  to  do 
with  the  excessive  rates  of  the  German  day  laborers,  but  they  are  perhaps 
no  more  potent  than  in  the  same  group  of  laborers  elsewhere. 

Exposure  to  the  elements,  dust,  and  tubercle  bacilli  are  predisposing 
factors  everywhere.  While  the  danger  of  infection  from  street  dust  has 
probably  been  overstated,  because  the  tubercle  bacilli  perish  under  the  in- 
fluence of  sunlight,  they  have  been  found  in  street  dust  by  Dr.  Robertson 
in  Birmingham  and  Martin  of  Leipsic.  Kristen  of  Breslau  has  shown  that 
they  may  survive  from  3-8  days  in  such  material. 

Preventive  Measures. — It  is  hoped  that  anti-spitting  ordinances  and 
the  modern  system  of  cleaning  streets,  by  means  of  sprinkling  and  sweeping 
machines,  will  be  generally  adopted  and  thus  reduce  the  dangers  of  dust 
inhalation  to  a  minimum.  The  wet  process  is  equally  applicable  to  the 
unloading  of  coal,  the  collection  of  ashes,  etc. 

All  dry  refuse  should  be  moistened  and  removed  under  cover.  A  higher 
scale  of  wages,  better  food  and  better  housing  conditions  are  indicated, 
and  will  do  much  toward  the  prevention  of  the  general  misery  of  this  class 
of  wage  earners. 

Fiske  presents  tables  of  occupational  distribution  of  physical  disability  in  the  personnel 
of  the  U.  S.  Navy.^2  jn  ^  personnel  of  62,251  ofiicers  and  men  for  a  period  of  six  j^ears  the 
non-effective  rates  per  1000  caused  through  sick  days,  invaliding  or  death  are  as  follows: 
Officers  31.88;  midshipmen  35.01;  electricians  32.61;  engine  room  force  37.74;  fire  room 
force  45.02;  all  other  artificers  40-23;  clerical  force  31.16;  culinary  force  40.50;  hospital 
corps  men  48.90;  marines  58.17;  musicians  26.15;  prisoners  16.20;  apprentice  seamen 
110.84;  ordnance  26.75.  All  other  in  the  seaman  branch  35.55.  Practically  over  11  per 
cent,  of  apprentice  seamen  and  nearly  6  per  cent,  of  the  marines  were  unavailable  for  duty, 
while  all  the  other  groups  show  a  disability  rate  of  less  than  5  per  cent. 

The  admission  rate  for  affections  of  the  eye  varied  from  10.97  for  the  whole  service  to 
154.60  for  midshipmen.  The  admission  rate  for  diseases  of  the  ear  was  especially  high  in 
apprentice  seamen,  marines  and  coal  passers.  The  admission  rate  for  mental  diseases  was 
relatively  high  for  apprentice  seamen,  fire  room  force,  hospital  corpsmen  and  marines. 


LIBERAL  PROFESSIONS,    ETC.  719 

f 

The  rates  for  neurasthenia  were  8.84  for  officers,  4.95  for  yeomen,  3.58  for  hospital  corpsmen 
and  3.05  for  musicians.  The  admission  rate  for  skin  diseases  was  lowest  (16.56)  in  hospital 
corpsmen,  next  (19.16)  in  yeomen  and  highest  177.36  for  midshipmen.  In  the  latter  class 
Surgeon  Fiske  believes  that  the  swimmmg  pool,  carelessness  in  using  others  towels,  soap, 
athletic  clothes  and  infected  gymnasium  apparatus  deserve  attention.  The  admission 
rate  for  respiratory  diseases  for  apprentice  seamen  was  103.07  per  1000  against  an  average 
of  22.80  for  the  service  at  large.  The  admission  rate  for  tuberculosis  for  apprentice  seamen 
was  7.04  per  1000  against  5.26  for  the  whole  service.  The  death  rate  from  all  respiratory 
diseases  for  apprentice  seamen  (years  1909-1914)  was  7.58  per  1000,  approximately  50  per 
cent,  higher  than  for  any  other  occupational  group  of  the  Navy.  In  addition  to  unfavor- 
able climatological  naval  training  stations,  mentioned  by  Fiske,  it  is  possible  that  close 
quarters  favor  contact  infections. 

^Midshipmen  have  a  very  high  injury  rate,  204.52.  The  fire  room  force  shows  a  rate  of 
100.93;  engme  room  force  83.52;  electricians  62. 87;  Surgeon  Fiske  believes  that  these  rates 
warrant  remedial  measures  in  athletics  and  safety  devices  in  shopwork,  etc.  Rheumatic 
and  heart  affections  are  especially  high  in  recruits,  coal  passers,  marines  and  apprentice 
seamen. 

REFERENCES 

^  Hunt,  J.  R. — Journal  A.  M.  A.,  Apr.  3,  1915,  page  1139. 

*  Oliver. — Diseases  of  Occupation,  London,  1908. 

'  Hoffman,  F  .  L. — Exhibits  of  the  Prudent.  Ins.  Co.,  Washington,  191 2. 

*  Hoffman,  F.  L. — Exhibits  of  the  Prudent.  Ins.  Co.,  Washington,  1912. 

*  Chajes,  Benno. — Weyl's  Handbuch  d.  Arbeiterkrankheiten,  Jena,  1903,  page  578. 

*  Koelsch. — Krankheit  und  Soziale  Lage,  Miinchen,  1912,  ist  Liefg.,  page  211. 

^  Verletzungen  des  Gehororgans,  1903.     Die  Betriebsunfalle  der  Telephonistinen,  1906. 

*  Capart. — Annales  d'hygiene  pub..  Vol.  XVIII,  page  711. 
'  Castaneda. — Boletin  de  laringologia,  Apr.-June,  191 2. 

^0  Trans.  15th  Intern.  Congress  on  Hygiene,  Washington,  1913,  Vol.  Ill,  part  II,  page  711. 
^^  Krankheit  und  Soziale  Lage,  Miinchen,  1912,  1st  Lief.,  page  212. 
*^  Archiv  f.  Eisenbahnwesen,  1907,  Heft  I. 

^'  Schwechten. — Weyl's  Handbuch  der  Arbeiterkrank.,  1908,  page  593. 
"  EdsaU,  D.  L.— J.  A.  M.  A.,  Vol.  LIH,  1909,  page  1876. 
^^  Hedinger. — Zeitschf't  d.  Vereins  d.  Eisenbahnverwaltg,  No.  27,  page  25. 
"  Exhibits  of  the  Prudential  Insurance  Company  of  America,  19 12. 
"  Weyl,  Theo. — Weyl's  Handbuch  d.  Arbeiterkrankheiten,  Jena,  1908,  page  595. 
"Weyl's  Handbuch  d.  Arbeiterkrankh.,  Jena,  1908,  page  598. 
"  New  York  Medical  Record,  April  21,  1906,  page  614. 
^"Scientific  American,  Aug.  31,  1907,  page  146. 

21  Delavan,  D.  B. — Med.  Record,  N.  Y.,  1910,  LXXVIII,  pages  305-309. 
"  Box,  Dr. — British  Medical  Journal,  Apr.  4,  1908,  page  807. 
^^  Oliver. — Diseases  of  Occupation,  London,  1908,  page  386. 
"  Borattaue,  H. — Gesundheit,  Berlin,  1905,  pages  688-695. 
"Le  Gendre. — Wiener  Mediz.  Presse,  1907,  pages  586-590. 
2*  Hoffman,  F.  L.— Bull.  Bureau  of  Labor,  No.  82,  May,  1909,  pages  481-485. 
"  Hoffman,  F.  L. — ^Mortality  from  Consumption  ia  Certain  Occupations.     Bull.  Bureau  of 
Labor,  No.  82,  May,  1909,  pages  475-481. 

28  Koelsch. — Krankheit  in  Soziale  Lage,  ist  Liefg.,  Munchen,  1912,  page  212. 

29  EdsaU,  D.  L. — Journal  American  Medical  Association,  Vol.  LXXI,  1909,  page  1878. 
3°  Oliver's  Dangerous  Trades,  1902,  page  279. 

^1  Kryz. — Zeitschrift  f.  Gewerbehygiene,  etc.,  191 2,  Vol.  IX,  page  62. 

32  Fiske,  C.  N. — Surgeon  U.  S.  Navy,  in  Naval  Med.  Bulletin,  Vol.  X,  No.  2,    1916. 


720        ETIOLOGY   AND    PROPHYLAXIS    OF   OCCUPATIONAL   DISEASES 


LIST  OF  INDUSTRIAL  POISONS* 

(Translated  by  Wm.  H.  Rand,  M.  D.) 


Designation  of  the 
substance 


Branches  of  industry     j^^^g  ^f  entrance 
in  which  poisoning  ^^^^  ^.j^g  ^^^^ 

occurs 


Symptoms  of  poisoning 


ACET  ALDEHYDE,  Manufacture  of  vine-  In  the  form  of  va-' Irritation  of  the  mucous  membranes 
ETHY  ALDEHYDE,!  gar;  silver  mirror  man-  por,  through  the,  of  the  nose,  larynx,  and  bronchi; 
CH3COH:    A    colorless,!  ufacture.  respiratory      o  r -i  irritation  of  the  mucous  membrane 


very    volatile    fluid,    of 
pungent  odor. 


gans  and  mucous 
membranes. 


ACRIDINE,    C13H9N:  Organic  dyes  industry.  Exerts     effect     in 


Crystallizing  in  colorless 
needles;  contained  in 
anthracene. 


any  state  of  ag- 
gregation on  skin 
and  mucous  mem- 
branes. 


of  the  eyes;  acceleration  of  the 
heart's     action;     profuse     night 

sweats. 


Irritation  and  inflammation  of  skin 
and  mucous  membranes;  severe 
burning  and  itching  of  the  skin; 
violent  sneezing. 


ACROLEIN,  C2H3COH: 
A  colorless,  very_  pun- 
gent smelling  fluid,  of 
fiery  taste. 


In    the    frying    out    of, In  vaporous  form,  Itching  in  the  throat;  irritation  of 


fat  and  fat-containing  through 
material,  e.g.,  in  bone  gans  of 
rendering  plants;  oil-  tion  and  the  mu- 
cloth  and  linoleum  cous  membranes, 
factories;  varnish-, 
boiling  shops;  tallow- [ 
rendering       establish-,  » 

ments;  soap  factories' 
(sulphuric  acid  proc- 
ess), and  stearic-acid 
factories. 


the    or-    the   eyes,   exciting  lachrymation, 
respira-i  conjunctivitis;  irritation  of  the  air 
passages,  bronchial  catarrh. 


In    gaseous   form,  A  proportion  of  more  than  o. is  per 
through    the    or-    cent,  of  ammonia  in  the  air  imme- 
gans    of    respira-   diately  causes  an  irritable  condi- 
tion. Seldom  tion  of   the  mucous  membranes, 
pure,    mostly    in    Chronic    bronchial    catarrhs    are 
combination  with   especially   liable   to   follow   long- 
other  gases.  continued     inhalation     of     small 
Immediate    effect   quantities  of  the  gas  diffused  in  the 
on    the    conjunc-    air.    Prom  these  are  to  be  discrim- 
tiva  and  the  c'or-   inated    the    acute    conditions    of 
nea.  transient    illness:    Intense    irrita- 
tion of  the  respiratory  organs;  vio- 
lent sneezing;  lachrymation,  red- 
ness of  the  eyes,  inflammation  of 
the  cornea  and  of  the  conjunctiva; 
increased  secretion  of  saliva;  burn- 
ing in  the  pharynx,  and  a  sense  qt 
constriction  in  the  larynx;  parox- 
ysmal   cough,    with    secretion    of- 
tenacious,    viscid,    even    bloody, 
mucus;  embarrassment  of  respira- 
tion, attacks  of  suffocation;  vom- 
iting ofserousmasses;  ammoniacal 
odor  of  the  perspiration;  retention 
of   urine,   which   may   last   many 
hours    and    even    2    or    3    days; 
acute  inflammation  of  the  respira- 
tory organs,  and  scattered  areas  of 
inflammation  in  the  lungs,  in  se- 
vere cases,  a  fatal  outcome.     Pro- 
tracted breathing  of  small  quan- 
tities   is    apt    to    cause    chronic 
bronchial  catarrh. 

Special  measures  of  relief :  Immediate  removal  from  the  poisonous  atmosphere;  artificial  respiration; 
inhalation  of  steam;  faradic  stimulation  of  the  phrenic  nerve;  free  bloodletting;  in  case  of  obstinate 
spasm_of  the  glottis,  tracheotomy. 


AMMONIA,  NH3:  A'Coke  ovens;  mirror- 
colorless  gas  of  sharply  silvering  industry; 
pentrating  odor.  :  coating  iron  plate  with 

tin  or  zinc;  manufac- 
ture of  solidified  am- 
monia, sulphate  and 
chloride  of  ammonium 
(sal  ammoniac)  from 
ammonia  water;  man- 
ufacture of  the  car- 
bonate of  soda  and  of 
orselle  dye-stuffs;  dye- 
ing industry;  sewer 
cleaning;  manufacture 
of  bone  black;  gas 
plants;  varnish  and 
lacquer  manufacture; 
tanning;  beet-sugar 
manufacture;  manu- 
facture of  ice;  refriger- 
ation plants. 


*  Prepared  by  Prof.  Dr.  Th.  Sommerfeld  and  Dr.  R.  Fischer,  and  Edited  by  Per- 
manent Advisory  Council  of  Hygiene  of  the  International  Association  for  Labor  Legislation. 
Published  in  Bulletin  No.  100,  Bureau  of  Labor,  Washington  D.  C,  May,  191 2, 


INDUSTRIAL   POISONS,    ETC. 
List  of  Industrial  Poisoxs — Continued 


721 


Designation  of  the 
substance 


Branches  of 

industry  in  which 

poisoning  occurs 


Mode  of 

entrance  into 

the  body 


Symptoms  of  poisoning 


AMYL  ACETATE,  Zapone  1  a  c  q  u  e  r  In  the  form  of  Nervous  symptoms;  headache;  fullness 
C5H.11CH3CO2:  Zap-  used  as  a  lacquering  vapor  through  of  the  head;  giddiness;  nausea;  numb- 
one,  a  solution  of  cell-  agent  in  metallic  the  respiratory  ness;  disturbances  of  digestion;  palpita- 
uloid  in  amyl  acetate   ware     and     jewelry    organs.  tions  of  the  heart, 

and  acetone.  factories;         manu- 

facture of  metallic 
wire  for  incandes- 
cent electric  lamps; 
oilcloth  manufac- 
ture. 


AMYL    ALC O HO  L,  Manufacture  of  fruit  In  the   form   of  Congestion  of  the  head;  headache;  oppres- 
CsHiiOH:  A  colorless,    essences,    nitrite    of   vapor    through   sion   of  the  chest;   irritation  of  the  air 
oily     fluid,     of     very    amyl,    valeric   acid,    the    organs    of    passages, 
sharp  taste  and  pene-    and     aniline     dyes;   respiration, 
trating,     disagreeable   rectification    of 
odor.  spirits. 


ANILINE,C6H5(XH2):  Manufacture  of  ani- 
A  colorless   oil   which   line  and  its  deriva- 
acquires  a  tint  on  ex-   tives,  as  well  as  of 
posure  to  air  and  light,    aniline  dyes;  manu- 
Like  aniline,  all  other   facture     of     photo- 
amide    compounds    of   graphic       materials 
benzol  and  its  homo-    and  the  like, 
logues,       as       toluol, 
naphthaline,    xylol, 
etc.,  are  poisons. 

Especially  shovdd  be 
mentioned  alpha  and 
beta  naphthylamine, 
benzidine,  tolidine, 
paranitraniline,  the 
diamines  (phenylene 
and  tolylene  diamine) 
as  well  as  the  alphyl 
and  aryl  compounds 
of  aniline,  like  their 
homologues  (dimethyl 
and  diethyl  aniline, 
diphenylamine,  etc.). 


.\bsorption 
through  the 
skin,  by  direct 
contact  or  by 
saturation  of 
the  clothing; 
through  the  di- 
gestive organs; 
absorption 
through  the 
respiratory  or- 
gans as  volatile 
particles  and 
impalpable 
dust. 


The  toxicity  of  the  separate  products  is 
very  different  in  degree;  the  para  com- 
pounds are  usually  more  poisonous  than 
the  ortho  and  meta  compounds. 

Acute  Poisoning. — (a)  Mild  cases: 
Pallor  of  the  skin  and  mucous  mem- 
branes, with  slight  cyanosis;  a  feeling  of 
weariness  and  weakness;  head  symptoms 
— vertigo,  reeling,  unsteady  gait;  defi- 
cient elasticiy  of  movement;  slow,  la- 
bored speech;  irritability  (aniline  "pip"); 
condition  of  slight  inebriation,  with  lo- 
quacity, gaiety,  and  defective  power  of 
orientation;  loss  of  appetite,  constipa- 
tion, and  tense,  rapid  pulse. 

(fe)  Severe  cases:  Dark  blue  to  swarthy 
cyanosis;  formation  of  methemoglobin; 
bounding  pulse;  "air-hunger,"  with  great 
frequency  of  respiration;  lowering  of 
sensibility;  obliteration  of  the  reflexes; 
sometimes  vomiting,  strangury  and 
bloody  urine. 

(c)  In  the  most  serious  cases:  Sudden 
prostration;  cold,  pale  skin,  blue  lips, 
nose  and  ears;  diminution  and  even  ex- 
tinction of  sensibility;  moist,  cold  skin; 
small  pulse;  death  in  a  comatose  condi- 
tion, sometimes  after  antecedent  con- 
vulsions. 

Subacute  and  Chronic  Poisoning. — 
Ana;mia;  slowing  of  the  pulse;  disorders 
of  digestion,  such  as  eructations,  loathing 
of  food,  vomiting,  diarrhea,  and  eczema- 
tous  and  pustular  eruptions  on  various 
parts  of  the  body,  especially  on  the  scro- 
tum; nervous  symptoms,  as  general 
debility,  headache,  ringing  in  the 
ears,  vertigo,  unrestful  sleep,  disturb- 
ances of  sensibility,  often  also  of  motility; 
spasmodic  muscular  pain.  Subacute 
and  chronic  poisonings  are  very  rare. 
Anamia  and  retarded  pulse  are  early 
symptoms. 

The  blood  is  of  a  brownish  hue,  but 
microscopically  unchanged;  occasionally 
the  urine  contains  blood. 

Measures  of  relief:  At  the  first  symptoms  of  poisoning,  immediate  removal  from  the  workroom  to  a  cool 
shady  spot;  change  of  clothing;  cool  affusions;  administration  of  oxygen  in  connection  with  artihcial 
respiration;  in  severe  cases,  bloodletting  with  subsequent  infusion  of  physiological  salt  solution;  copious 
ingestion  of  milk;  in  case  of  weak  action  of  the  heart,  stimulants  (black  coffee,  camphor,  ether,  but  no 
alcohol) ;  caution  against  the  use  of  alcohol  during  and  immediately  after  labor;  abstinence  is  advisable. 


46 


722        ETIOLOGY   AND   PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 

List  of  Industrial  Poisons — Conlinued 


Designation  of  the 
substance 


Branches  of 
industry  in  which 
poisoning  occurs 


ANILINE  DYESTUFFS:  The  majority  of 
the  very  numerous  aniline  dyes  are  non- 
poisonous.  Generally  the  basic  dyes  are 
more  dangerous  than  the  acid  dyes. 
Regarded  as  suspicious  or  injurious  to 
health  are — 

(a)   The  various  phe-lAniline  dye  factories; 
nol    nitrates,     dinitro-!  d  y  e  h  o  us  e  s;  also 
phenol,        dinitrocresol   manufacture  of  ex- 
(safiron  yellow,  aniline,  plosives, 
orange),      picric      acid 
(trinitrophenol). 


(6)  The  many  naph- 
thol  nitrates,  dinitro- 
naphthol,  Manchester 
yellow,  dinitro  and 
naphthol  calcium;  tet- 
ranitronaphthol. 

(c)   The  nitroso  dyes. 


(d)  The  aurantia — 
hexantrodiphenyl- 
amine;  imperial  yellow, 
its  sodium  salt. 

(e)  Ethyl  and  methyl 
violet. 


(/)  The  Meldola  dyes, 
corvulin,  indulin,  fast 
black. 


Aniline  dye  manu- 
factories; dye- 
houses. 


Aniline  dye  manu- 
factories; dye- 
houses. 

Aniline  dye  manu- 
factories; dye- 
houses. 

Aniline  dye  manu- 
factories ;  dye- 
houses  manufac- 
ture of  colored 
pencils. 

Aniline  dye  manu- 
factories; dye- 
houses. 


Mode  of  entrance 
into  the  body 


(g)   Chrysoidin,      fast  Aniline    dye    manu- 
black.  I  factories;    dye- 

houses. 

(/i)  Bismarck  blue  ...Aniline  dye  manu- 
factories; dye- 
houses. 


Action  on  the  skin; 
in  the  form  of  dust, 
through  the  respir- 
atory _  organs;  the 
digestive  organs. 


Action  on  the  skin; 
in  the  form  of  dust, 
through  the  respir- 
atory organs;  the 
digestive  organs. 

In  the  form  of  dust 
on  the  skin. 


In  the  form  of  dust 
on  the  skin. 


As  dust  or  fine  par- 
ticles in  the  eyes. 


As  dust  or  atorn- 
ized  solution  (in 
dyeing  by  the 
spraying  process) ; 
action  on  the  skin 
and  respiratory  or- 
gans. 

In  the  form  of  dust; 
effect  on  the  skin. 


Symptoms  of  poisoning 


ANTIMONY  COM- 
POUNDS: 
Trioxide    of    antimony, 

bb203. 

Antimony       trichloride, 

SbCh  (antimonious 
chloride,  butter  of  an- 
timony, antimonial  ore 
butter). 

Tartar  emetic  (tartrate 
of  antimony  and  potas- 
sium),    2(C4HiKlSbO] 

06)H20. 

Golden  sulphide,  SbsSe 
(aiitimony  pentasul- 
phide),    antimony  col- 


Extraction  of  anti- 
mony and  its  com- 
pounds; burnishing 
of  rifle  barrels  and 
steel  ware;  manu- 
facture of  antimony 
alloys,type  and  ster- 
eotype metal,  hard 


In  the  form  of  vap- 
or (trioxide  of  anti- 
mony, antimonious 
acid,  sulphide  of 
antimony)  through 
the  organs  of  res- 
piration; irritation 
of  the  skin;  in  the 


Itching,  dermatitis,  efflorescent  erup- 
tion, yellow  discoloration  of_  the  cu- 
ticle and  conjunctiva;  sneezing  and 
nasal  catarrh;  inflammation  of_  the 
buccal  mucous  membrane;  bitter 
taste;  disturbances  of  digestion; 
irritation  of  the  central  nervous  sys- 
tem and  of  the  kidneys.  Picric  acid 
is  a  feeble  former  of  methemoglobin; 
industrial  poisonings  by  it  are  ex- 
tremely rare. 

Blood  poisons,  forming  methemo- 
globin. The  morbid  symptoms  re- 
semble those  in  poisoning  by  amido 
compounds;  ailments  of  the  central 
nervous  system  in  great  variety; 
paralyses. 

Intense  irritation  of  the  skin,  caused, 
it  is  asserted,  partly  by  using  exces- 
sive quantities  of  chloride  of  lime  in 
cleansing  the  skin. 

Intense  irritation  of  the  skin,  caused, 
it  is  asserted,  partly  by  using  exces- 
sive quantities  of  chloride  of  lime  in 
cleansmg  the  skin. 

Inflammation  of  the  conjunctiva  or 
the  cornea. 


Eruptions;  severe  irritation  of  the 
mucous  membranes;  uncontrollable 
sneezing. 


Eruptions  (probably  superinduced 
by  the  use  of  excessive  quantities  of 
the  chloride  of  lime  in  washing  the 
hands). 


lead  [ammunition!  form  of  dust,  in  the 
factories), britannia, I  manipulation  of 
and  white  metal;!  britannia  and  type 
remelting  of  old  and    metal. 


scrap  metal;  manu- 
facture    of     aniline 
dyes,  fireworks;  vul- 
canizing and  red-dyeing  of  India  rubber  (antimony  pentasulphide) ;  mordants 
and  fixing  materials  in  cotton  dyeing  and  textile  printing, 


Intensely  itching  eruptions  of  the 
skin,  caused  by  local  irritation  and 
aggravated  in  the  case  of  a  perspir- 
ing skin;  inflammation  of  the  mouth, 
throat,  and  stomach;  constipation 
and  intestinal  colic;  in  acute  cases, 
diarrhea,  albumin  in  the  urine,  loss 
of  strength,  weakness  of  the  heart, 
vertigo,  and  faintness. 

It  appears  to  be  somewhat  doubt- 
ful, however,  whether  all  of  the 
enumerated  compounds  of  antimony 
are  detrimental  to  the  health  off  the 
workers  in  them. 


INDUSTIOAL   POISONS,    ETC. 
List  of  Industrial  Poisons — Continued 


723 


Designation  of  the 
substance 


Branches  of 
industry  in  which 
poisoning  occurs 


Mode  of 

entrance  into 

the  body 


Symptoms  of  poisoning 


ARSENIC  COM-  Arsenic   m  i  n  i  n  g  ;  In  the  forms  of  Acute  PoisoninK. — The  first  symptoms 

POUNDS:  Arsenic  tri-  roasting  of  arsemc-  gas    and    dust,  usually  appear  after  half  an  hour  or  an 

oxide,     AS2O3     (arsenic,  bearing  ores;  manu-  through   the  hour,  viz.,  constriction  of  the  esopha- 

white    arsenic,    smelting  facture  of  glass,  col-  respiratory    or-  gus,  pains  in  the  stomach  and  bowels, 

dusf) ;  arsenous  chloride,  ored  chalk,  chloride  gans    and    mu-  vomiting,  diarrhea,  debility,  cold,  blu- 

AsCU;     arsenic     colors,  of  arsenic  for  etch-  cous    mem-  ish    skin,    sural    cramp,    lowering    of 

e-S- —  ing   on    brass;    shot  branes,    the  heart's  energy,  vertigo,  headache,  faint- 

Scheele's    green    (Swed-  manufacture;  metal  stomach,      and  ness,    illusions,    loss  of  consciousness, 

ish    green),    arsenite    of  working;    manufac-  intestinal  canal,  convulsions;    death,    sometimes    chol- 


copper.  ture  of  arsemc  col- 

Schweinfurt  green  (pat-  ors;  preparation  of 
ent,  original,  new,  moss,  organic  dyestufifs, 
mountain,  parrot.  May,  colored  lights,  tex- 
Kaiser,  Cassel,  Pari^  tile  printing,  and 
Vienna, Kirchberg,  dyeing;  manufac- 
Leipsic,  W  u  r  z  b  u  r  g,  ture  of  wall- paper 
Swiss  green),  compound  and  colored  paper; 
of  the  arsenite  and  the  tanning;  manufac-| 
sulphide  of  copper.  ture  of  oilcloth  andj 

Brunswick  green,  oxy-  artificial  flowers;! 
chloride  of  copper  with  taxidermy  painting| 
copper  oxide  and  sul-  (outside  and  decora- 
phate  of  lime. 

Neuwied  green.  (Similar, 
only  a  larger  proportion 
of  arsenic  trioxide.) 

Cochineal   (Vienna  red), 

arsenic  acid  with  ex-  per,  and  the  com- 
tract  of  Pernambuco  mercial  acids  often 
wood.  contain  more  or  less 


tive) ;  pyrotechnics! 
(Indian  white-fire).  ! 
It  is  to  be  observed] 
that  zinc,  silver,! 
lead,  bismuth,  cop- 


eraic  symptoms.  In  mild  cases,  burn- 
ing in  the  pharynx,  vomiting,  salivation, 
difficult  deglutition  and  indigestion. 
Chronic  Poisoning. — Constant  and 
persistent  headache  combined  with 
melancholia,  disinclination  to  labor, 
and  sleeplessness,  which  are  sometimes 
the  only  symptoms;  further,  gastric 
disturbances,  such  as  vomiting  and 
diarrhea,  which  result  in  emaciation 
and  decline  of  strength;  persistent 
symptoms  of  catarrh  of  the  mucous 
membranes,  such  as  coryza,  pharyn- 
gitis and  bronchitis;  frequently  skin 
diseases  in  varying  form:  Erythema- 
tous, papular,  and  pustular  cutaneous 
eruptions,  which  also  produce  ab- 
scesses with  infiltrated  and  indurated 
borders;  falling  out  of  the  hair  and 
nails;  melanosis— that  is,  the  deposi- 
tion of  a  brownish  pigment,  not  con- 
arsenic.  [     '  j  taining   arsenic,   on   the   neck,   trunk, 

I  and  extremities. 

In  severe  cases,  disturbances  of  the 

central  nervous  system;  intense,  lightning  like,  lancinating  pains;  formication;  furriness  of  the  skin; 

impairment  of  the  sensibility;  chilliness;  weakness  of  the  muscles,  also  unilateral  or  bilateral   paralysis, 

and  often  loss  of  the  tendon  reflexes;  sometimes  fever;  albuminuria.     The  paralyses  are  transient,  or 

they  may  last  for  years,  leaving  not  infrequently  permanent  disturbances. 

Special  measures  of  relief :  If  arsenic  has  been  ingested,  thorough  gastric  lavage  is  necessary;  then  ad- 
minister at  once  by  the  mouth  five  tablespoonfuls  of  a  solution  of  calcined  magnesia  (70  g.  to  soo  g.  of  dis- 
tilled water);  afterward  give  a  tablespoonful  every  s  minutes  until  a  movement  of  the  bowels  occurs; 
the  internal  use  of  lime  water  also  is  recommemded  for  rinsing  out  the  stomach  and  as  a'n  antidote;  to 
counteract  the  exhaustion,  cold  affusions,  rubbing,  hypodermic  injections  of  ether  and  camphor.' 
'  Hydrated  sesquioxide  of  iron  is  not  mentioned. 

In  case  of  chronic  arsenical  poisoning:  Electric  vapor  baths  and  electrical  treatment  are  in  order;  the 
disturbances  of  the  stomach  are  to  be  treated  with  calcined  magnesia  and  unirritating  liquid  nourish- 
ment (milk,  milk  porridge,  rice  porridge,  salep);  the  cachexia,  by  fresh  air  and  nutritious  diet,  in  pa- 
ralyses, use  iodine  preparations  and  electricity. 


ARSENIURETED     HY-  This   gas   is   formed  In  the  form  of  a 

DROGEN,  AsHs:  A  col-    everywhere  when,  in   gas,    through 

orless,    extremely   offen-   the  use  of  arsenical   the    organs    of 

sive   gas   with   the   odor   acids     and     metals,  respiration 

of  garlic.  ■  hydrogen   is   gener-    (generally  mix- 

I  ated    for    technical   ed  with  hydro- 
purposes    (e.g.,    the    gen), 
filling   of   children's 
toy    balloons) ;      in 
soldering  and  etch- 
ing,    with     arsenic- 
containing      metals 
or  acids,  e.g.,  enam- 
el ware  factories,  tin,  zinc,  and  lead 
plating  works;  impure  iron  silicate, 
by  the  absorption  of  water,  develops 
arseniuretted  hydrogen.  I 

Special  measures  of  relief :  Fresh  air  and  oxygen;  later  bloodletting;  use  of  an  alkaline  solution  of  com- 
mon salt;  mild  alkaline  drink;  analeptics  (coffee,  camphor). 


At  first  no  disturbance,  or  only  slight 
indisposition;  after  some  hours,  chilli- 
ness, vomiting  (food,  bile,  then  blood), 
pain  in  the  back,  giddiness,  ringing  m 
the  ears,  faintness,  small  pulse,  bluish 
discoloration  of  the  mucous  mem- 
branes; labored  respiration;  urine  at 
times  dark  or  even  black,  containing 
blood  or  hemoglobin. 

After  24  hours,  yellow  hue  of  the  skin 
and  mucous  membranes,  from  absorp- 
tion of  biliary  fluids,  fetor  of  the 
mouth  (resembling  garlic),  swelling 
and  sensitiveness  of  the  liver  and 
spleen,  headache,  delirium,  mortal 
anguish;  death  or  slow  convalescence. 


724         ETIOLOGY    AND    PROPHYL.AXIS    OF    OCCUPATIONAL    DISEASES 
List  of  Industrial  Poisons — Continued 


Designation  of  the 
substance 


Branches  of  Mode  of 

industry  in  which        entrance  into 
poisoning  occurs  the  body- 


Symptoms  of  poisoning 


In  the  form  of  Headache,  vertigo,  nausea,  vomiting, 
vapor,  through!  cough,  irregular  respiration,  weakness 
the  respiratory'  of  the  heart,  drowsiness,  and  deep  sleep 
organs;  to  a  with  cyanosis  of  the  countenance,  cold- 
less  extent,  ness  of  the  skin  and  complete  insen- 
probably,'  sibility;  on  awaking,  headache,  vertigo 
through  the  and  depression,  fibrillar  twitching  of 
skin  also.  ,  the   muscles,   trembling,   especially   of 

j  the  musculature,  as  if  from  chilliness. 
Benzoic  acid  is  found  in  the  urine. 

Chronic  Poisoning. — Headache, 
flashes  before  the  eyes,  ringing  in  the 
I  ears,  psychosis  with  excitement  and  a 
state  resembling  inebriation,  sensory 
disturbances  and  hallucinations  (but 
the  prodromata  of  chronic  benzine 
poisoning  will  also  appear).  The  oc- 
currence of  chronic  poisoning  by  ben- 
zine has  been  contested. 

The  symptoms  vary  greatly  because 
the  benzine  used  technically  is  a  com- 
plex mixture  and  not  always  of  the 
same  composition. 

Special  measures  of  relief :  Removal  of  the  patient  into  fresh  air;  in  severe  cases,  stimulants,  like  cofifee, 
camphor;  then  cold  affusions. 


BENZINE:  A  mixture  of i Benzine  distillation; 
low-ebullition  portions,  chemical  cleansing 
of  petroleum,  known'  plants,  glove  clean- 
commercially  under  va-  ing;  removal  of  fat 
rious  names,  e.g.,  petro-;  from  bones,  fat  sol- 
leum,  benzine,  ligroine,  vent;  lacquer,  var- 
gasoline.  rish.  and  India  rub- 

ber industries;  man- 
ufacture of  water- 
proof materials 
(application  of  the 
rubber  mass  dis- 
solved in  benzine) ; 
ornamental  feather 
factories;  used  as  a 
I  source  of  power. 


BENZOL,  CeHe:  A  very' Manufacture  of  ben-|ln  the  form  of  Benzol,  its  homologues  and  the  rest  of 
unstable,  colorless  fluid,    zol,   its  homologues ,  vapor,  through   the  hydrocarbons  of  coal  tar,  have  a 
and    numerous    de-;  the  respiratory   specific  affinity  for  the  central  nervous 


burning  with  a  bright, 
very  sooty  flame;  ex- 
tremely volatile;  its  ho- 
mologues, e.g.,  toluol- 
xylol,  and  cumol. 


organs;  reab-  system  and  a  general  action  on  the 
sorption  protoplasm  of  the  organic  cells  (fatty 
through  the  degeneration).  Female  workers,  par- 
ticularly in  their  developmental  years, 
especially  at  the  time  of  menstruation, 
are  more  susceptible  than  men  to  the 
poisoning  and  in  an  extraordinary  de- 
gree to  the  subacute  and  chronic  forms 
of  it. 

Acute  Poisoning. — (a)  In  mild  cases: 
Cerebral  disturbances,  humming  in 
the  ears,  giddiness,  somnolence,  a  con- 
dition resembling  inebriation,  vomit- 
ing and  irritant  cough,  slight  flushing 
of  the  face.     There  is  often  euphoria. 

(6)  In  sej'ere  cases:  Symptoms  on  the 
part   of    the   central   nervous   system, 
muscular  tremor,  like  chilliness  from 
exposure  to  cold ;  trembling  of  the  whole 
extremities;   finally,   tonic   and   clonic 
spasms;  euphoria;  pale,  livid  skin;  lips 
remarkably  scarlet  hued;  blood  bright 
red.  thin.      Discolorations  of  the  slan. 
like  those  in  aniline   and   nitrobenzol 
poisoning,     are     wanting    in     benzol 
poisoning, 
(f)  In  the  most  violent  cases:  Halluci- 
nations, delirium,  protracted  unconsciousness,  and  death  in  tonic  convulsions. 
Subacute    and    Chronic    Poisoning. — Numerous    spots    of    extravasated 
blood  in  the  skin  [petechise]  similar  to  those  of  morbus  maculosus,  together 
with  severe  anasmia;  hemorrhage  from  the  mucous  membranes — in  women, 
from  the  genitals;  fatty  degeneration  of  the  internal  organs  (heart,  liver, 
kidneys). 

Special-measures  of  relief:  Prompt  removal  of  the  patient  into  the  fresh  air;  inhalation  of  oxygen;  ex- 
clusion of  female  workers  from  every  employment  in  which  benzol  is   used. 


;  rivates;  technical 
use  of  these  prod- 
ucts   in   the    manu- 

'  facture  of  colors,  inl  skin, 
carburizing     illumi- 
nating and  water  gas 
in  refining  and  dis- 

[  solving  of  caout- 
chouc,   resins,    fats, 

j  alkaloids,  iodine, 
phosphorus,  and 
sulphur;  in  the  re- 
moval     of      grease 

(  from    materials; 

i  dye  works,  laun- 
dries;   lacquer    and 

i  varnish       factories; 

1  the  rubber  indus- 
try. 


INDUSTRIAL   POISONS,    ETC. 

List  of  Industrial  Poisons— Co>i7/n«c</ 


725 


Designation  of 
the  substance 


Branches  of 

industry  in  which 

poisoning  occurs 


Mode  of 

entrance  into 

th«  body 


CARBON  DIOXIDE,  Generated  in  mines  In  the  form  of 
CO2:  A  specifically  by  the  process  of  gas  by  inhala- 
dense,  odorless,  color-    breathing,     by     the   tion.  I 

less      gas,      collecting    burning    of    miners',  j 

near    the    ground    or   lamps,  and  by  blast-  I 

floor.  I  ing;     in     lime     and 

i  brick  kilns  and  dolo-i 
I  mite  calcining  kilns; 
■  in  decomposition! 
and     putrefaction'  i 

gases;    in     tanneries!  I 

(tan  pits) ;  in  sugar 
mills  (saturation 
vessels);  manufacture  of  carbonic 
acid  and  of  mineral  waters;  spirit  dis- 
tilleries, compressed  yeast  factories, 
breweries,  fermenting  rooms  and 
wine  cellars;  in  sewer  and  well  gases; 
in  firing  and  heating  establishments; 
in  the  lighting  of  workrooms;  by  the 
exhaled  air  in  closed  workrooms  and 
caissons.  1 


Symptoms  of  poisoning 


Large  quantities  occasion  sudden  death 
by  suffocation. 

With  the  inhalation  of  smaller  quan- 
tities the  symptoms  of  illness  begin  with 
pressure  in  the  head,  vertigo,  ringing  in 
the  ears  and  sparks  before  the  eyes,  dis- 
turbances of  respiration,  such  as  hurried 
breathing  and  pain  in  the  chest,  some 
times  psychic  excitement  and  con- 
vulsions. Usually  in  case  of  more  pro- 
tracted effect  there  is  loss  of  conscious- 
ness and  of  the  power  of  motion  (or  even 
death  by  suffocation),  with  gradual  de- 
cline of  the  pulse  and  respiration,  and 
.  often  with  the  occurrence  of  delirium. 

On  prompt  removal  from  the  poisonous 
atmosphere  therp  is  a  restoration  of 
consciousness  >vith  subsidence  of  the 
symptoms  of  illness  and  recovery  in  a 
few  days. 

The  occurrence  of  chronic  poisoning  by 
carbon  dioxide  is  doubtful. 


Special  measures  of  relief:  Examination  of  the  air  of  the  suspected  places  before  entering  them ;  imme- 
diate removal  from  the  poisonous  atmosphere;  artificial  respiration  to  be  persevered  in  for  a  long  time; 
finally  inflation  of  the  lungs  with  oxygen;  cold  aflusions;  stimulation  of  the  sldn;  restoratives. 


CARBON    DISUL-j  Manufacture  of  CS2;  In  the  form  of, It  causes  heavy  damage  to  the  red  blood 

PHIDE    (carbon    sul-   an  agent  for  extrac-  vapor,  through  1  corpuscles   and   to   the   central   nervous 

phurate),    CS2:    In    a   tion  of  sulphur  from  respiration;     ini  system. 

pure  state  it  is  a  lim-   the     mass     in     the  fluid   form  ,1    Acute      Poisoning. — In      mild      cases, 
pid,  highly  refractive,'  process  of  gas  puri-:  through   the'  marked  stupefaction  and  a  sense  of  in 

extraordinarily     vola-i  fication;       disinfec-  skin,  e.g.,  at  the,  toxication;    in    more   intense    poisoning, 

tile    fluid,    having    an,  tion;    a    solvent   for  dipping   of   the   pallor  of  the  countenance,  flaccidity  of 

odor  like  that  of  chlo-    caoutchouc,     gums,  hands     in     the'  the  arms  and  legs,  even  complete insensi- 


roform;       imperfectly!  fats,    oils,    etc.;    in    fluid, 
refined,  its  hue  is  pale    vulcanizing   caout-, 
yellow    and    its    odor   chouc     and    rubber 
offensive.  I  (patent-rubber   fac- 

!  tories);   for  the   ex- 
I  traction   of   lanolin,, 
the   refining   of  tal- 
j  low,    stearin,    para- 
1  ffine,  and  wax;  pro- 
I  duction    of    carbon 
j  chloride;      assembl- 
1  ing   and   setting   up 
',  carriage-wheel   rims 
j  and     rubber     tires; 
imitation-silk  facto- 
ries. 


bility,  obliteration  of  all  reflexes,  loss  of 
consciousness,  due  to  paralysis  of  the 
nervous  system.  With  the  inhalation  of 
concentrated  vapor  there  is  a  fatal  result 
in  a  few  minutes. 

Chronic  Poisoning. — The  earliest  symp- 
toms (first  becoming  manifest,  some- 
times after  employment  for  a  few  weeks, 
but,  for  the  most  part,  after  months  or 
even  years)  are  headache,  extending  from 
the  root  of  the  nose  to  the  temples,  a  sen- 
sation of  giddiness  and  stupefaction, 
particularly  at  evening  after  the  close  of 
labor;  later,  pain  in  the  extremities,  mus- 
cular weakness  with  trembling,  spasms 
or  fibrillar  twitching,  also  contractures, 
transient  and  permanent  paralyses,  with 


atrophy  of  the  muscles;  deafness;  itching 
and  formication  on  the  skin,  reduction  of  the  reflexes,  circumscribed  and  more  extensive  areas  of  anaes- 
thesia and  analgesia;  acceleration  of  the  heart's  action,  nausea,  vomiting,  colic,  alternate  diarrhea  and 
constipation,  the  latter  condition  prevailing  in  the  later  stages  of  the  disease;  emaciation,  disturbance  of 
the  sense  of  vision,  sometimes  transient,  but  rare  in  the  initial  stage;  retrobulbar  neuritis,  choroiditis 
central  scotoma,  disturbances  of  the  senses  of  smell  and  taste.  In  respect  to  the  central  nervous  system 
there  is  at  first  a  condition  of  excitement,  followed  by  depression;  subsequently,  very  irritable,  violent, 
and  explosive  temper,  with  hyperstimulation  of  the  sexual  instinct;  later,  its  abnormal  decline.  After 
several  weeks  or  months,  relaxation,  melancholy,  a  dreamy  manner,  weakness  of  memory,  puerile 
enunciation,  obtuseness.  .  ».         1  j- 

According  to  Charcot,  psychic  disturbances  occur  m  87. S  per  cent,  of  the  cases.  Mental  diseases 
under  the  semblance  of  acute  mania  and  dementia  occur  with  good  prospect  of  recovery;  the  severer 
forms  appear  in  cases  where  there  is  hereditary  predisposition.  There  have  been  observed  also  local 
evidences  of  the  paralyzing  effect  of  the  carbon  disulphide  upon  the  parts  brought  into  contact  with  it, 
especially  in  the  fingers.  .         -  ,.,    .  j    ■    r  i_,  ^     ^t.    r  n        ^       *• 

The  prognosis,  so  far  as  the  preservation  of  life  is  concerned,  is  favorable;  as  to  the  full  restoration 
of  health,  it  is  unfavorable. 

Special  measures  of  relief :  In  acute  poisoning,  removal  into  the  fresh  air.  warm  baths,  cold  affusions; 
when  there  are  symptoms  of  paralysis,  electrical  treatment;  in  disturbance  of  vision,  potassium  iodide 
and  vapor  baths;  interdiction  of  the  practice  of  dipping  the  unprotected  hands  into  carbon  disulphide. 


726        ETIOLOGY   AND    PROPHYL.AXIS    OF   OCCUPATIONAL   DISEASES 

List  of  Industrial  Poisons — Continued 


Designation  of  the 
substance 


Branches  of 
industry  in  which 
poisoning  occurs 


Mode  of 

entrance  into 

the  body- 


Symptoms  of  poisoning 


CARBON   MONOXIDE,! 

CO:  A  colorless,  taste- 
less gas,  and,  when  in  a 
state  of  diffusion,  odor- 
less, burning  with  a  blue 
flame  in  the  air. 
Coal  vapor  has  from  o.S 

to  5  per  cent  of  CO. 
Illuminating  gas,  6  to  10 
per  cent,  of  CO  and  33 
to  40  per  cent,  of  mine 
gas. 

Water  gas,  a  mixture  of 
41  per  cent.  CO,  so  per 
cent,  hydrogen,  4  per 
cent.  CO2,  and  5  per 
cent.  N. 

Producer  gas  contains 
34  per  cent.  CO  and  60 
per  cent,  hj'drogen  gas. 


In  the  form  of  Acute  Poisoning. — ^Increased  blood 
gas,  through  pressure  at  first,  with  slowing  of  the 
the  respiratory  pulse  and  pounding  heart  beat;  later, 
lowering  of  the  pressure,  with  rapid 
but  small  pulse,  and,  not  infrequently, 
with  discrete  spots  of  dilatation  in  the 
superficial  blood  vessels.  Remarkably 
pale-red  discoloration  of  the  blood  and 
of  the  dilated  spots;  formation  of  car- 
bon monoxide  hemoglobin  is  demon- 
strable by  the  spectrum.' 

(o)  Disturbances  of  the  general  health: 
In  mild  cases,  dull  headache,  flashes 
before  the  eyes,  giddiness,  ringing  in 
the  ears,  nausea  and  fullness  in  the 
gastric  region. 

(6)  In  severe  cases:  Bluish  discolora- 
tion of  the  skin;  spasmodic,  wheezing 
respiration;  sometimes  tonic  and  clonic 
convulsions,  more  often  paralytic 
symptoms,  either  with  weakness  of  all 
the  extremities  or  of  the  lower  only,  or, 
indeed,  of  only  single  groups  of  mus- 
cles,including  also  the  facial  muscles. 

The  convulsive  stage,  which  may  be 
altogether  absent,  is  succeeded  by  the 
stage  of  asphyxia,  with  sensory  and 
motor  disturbances,  involuntary  void- 
ing of  urine,  semen,  and  feces;  sub- 
normal temperature;  weak,  slow  and 
intermittent  pulse;  loss  of  conscious- 
ness. 

As  sequels  there  have  been  observed 
pneumonias,  inflammations  of  the 
skin,  paralyses  and  psychoses,  the  last 
two  often  pursvdng  an  unfavorable 
course. 

Chronic  Poisoning  (among  ironers, 
firemen,  cooks,  etc.). — Frequent  head- 
aches, dizziness,  nausea,  vomiting, 
coated  tongue,  weakness  of  memory; 
anaemia  without  chlorosis;  "hot 
flushes,"  formication,  palpitation  of 
the  heart,  insomnia,  general  debility 
and  feebleness  of  the  psychic  functions. 

Special  measures  of  relief:  Removal  from  the  poisonous  atmosphere;  admission  of  fresh  air;  artificial 
respiration,  with  inflation  of  the  lungs  by  oxygen  for  hours,  if  necessary;  keep  head  of  the  injured  person 
slightly  elevated;  subcutaneous  injection  of  ether;  camphor;  cold  affusions;  rubbing;  mustard  poultice; 
electrical  treatment;  insufflation  of  ammonia  vapor;  administration  of  black  coffee;  alkaline  salt  infusion; 
entering  where  CO  may  be  generated  only  when  protected  by  safety  masks  and  by  a  constant  supply 
of  air. 


In  industrial  plants 
with  defectively 
planned  or  ill-tended 
firing  and  heating 
arrangements; 
plants  for  the  pro- 
duction of  indus- 
trial gas;  mining 
(mine  gases) ;  coal 
mines;  blast  fur- 
naces (furnace  gas) ; 
Cowper  apparatus; 
gas  purification; 
coke  ovens,  smelt- 
ing furnaces;  gas 
machines;  lime  and 
brick  kilns,  dolo- 
mite calcining  kilns; 
iron,  and  metal  foun- 
dries (drying  of  the 
moulds) ;  soldering 
in  tin  shops;  char- 
coal burning;  resin 
distillation;  ironing; 
heating  with  open 
coal  brasiers  or  coke 
stoves  (dry-ing  the 
plaster  and  walls  of 
new  buildings) ;  dry- 
ing chambers. 


1  An  elementary  knowledge  of  the  function  of  the  hemoglobin  is  indispensable  to  an  understanding 
of  the  deadly  effect  of  the  transformation  of  hemoglobin  into  "carbon  monoxide  hemoglobin."  When 
so  changed,  it  is  useless  in  the  body,  for  it  can  no  longer  carry  and  distribute  oxygen  to  the  tissues. 
Hence  all  of  the  blood  charged  with  this  poison  is  \-irtually  destroyed — lost  to  the  system  as  surely  as 
if  it  had  escaped  from  a  severed  artery.  So  if  a  considerable  proportion  of  the  blood  becomes  saturated 
with  this  gas,  death  is  inevitable,  not  by  suffocation,  as  commonly  imagined,  but  by  carbon  monoxide 
poisoning. — W.  H.  R. 

39538° — Bull.  100 — 12 2 


INDUSTRIAL   POISONS,    ETC. 

List  of  Industrial  Poisons — Continued 


727 


Designation  of 
the  substance 


Branches  of 
industry  in  which 
poisoning  occurs 


CHLORIDE   OF 

LIME,     CaOCh:     A 

white  granular,  some- 
w  h  a  t  desiccative 
powder,  having  the 
odor  of  hypochlorous 
acid,  and  containing 
35  to  40  per  cent,  of 
chlorine. 


Manufacture  of  the  chlo- 
ride of  lime;  use  of  the 
chloride  of  lime  as  an 
oxidizing  and  chlorinat- 
ing agent  in  the  chem- 
ical industry  (for  exam- 
ple, dyestuffs);  disin- 
fection; manufacture  of 
chloroform,  chlorine, 
oxygen;  bleaching  of 
linen,  cotton,  paper, 
cotton  print  works. 


Mode  of 
entrance   into^ 
the  body     I 


Symptoms  of  poisoning 


In  the  form  of 
vapor  or 
dust, through 
the  respira- 
tory organs 
(inhalation 
of  chlorine 
gas);  direct 
action  on  the 
skin. 


More  or  less  severe,  irritatinR  cough, 
symptoms  or  inflammation  in  the  upper 
air  passages;  difficulty  of  breathing, 
bronchitis,  asthma,  sometimes  hemop- 
tysis, irritation  of  the  conjunctiva,  lach- 
rymation;  skin  hot  from  action  of  chlo- 
rine; hyperhidrosis;  intensely  itching  and 
burning  eruption  on  the  skin,  eczema, 
burns  from  the  dust  of  lime  and  its 
chloride. 


Special  measures  of  relief:  Admission  to  the  employment  ov  such,  and  only  such,  workmen  as  are  sound 
and  strong  and  free  from  any  predisposition  to  catarrhal  affections;  technical  arrangements  which  per- 
mit the  charging  and  emptying  of  the  chambers  from  the  outside. 


CHLORINE,    CI:    A 

yellowish-green,  suf- 
focating gas,  of  pene- 
trating odor,  which 
forms  a  solution  of  a 
greenish-yellow  color 
when  dissolved  in 
water. 


Manufacture  of  chlorine, 
chloride  of  lime,  and  of 
organic  chlorine  prod- 
ucts; bleacheries;  pa- 
per mills;  laundries; 
ironing;  tinning  works; 
manufacture  and  use  of 
disinfecting  agents  con- 
taining chlorine. 


In  the  form  of  The  smallest  quantities  excite  severe  suf- 
gas,  through  locative  sensations  and  necessitate  leav- 
the  respira-  ing  the  room,  so  that  acute  chlorine 
tory  organs,      poisoning  seldom  occurs. 

Symptoms  of  Cutaneous  Disease. — 
Burning,  stinging,  formation  of  nodules, 
blebs,  and  even  open  wounds  of  the  skin. 
Effect  on  the  Mucous  Membranes. — 
Lachrymation,  coryza,  cough,  oppression 
of  the  chest  and  intense  dyspnoea;  bron- 
chial catarrh  with  hemorrhage;  some- 
times lobular  pneumonia.  The  con- 
centrated vapor  causes  uncontrollable 
cough,  spasm  of  the  glottis,  dyspnoea, 
cold  sweats,  cyanosis  and  small  pulse; 
death  occurs  within  a  few  minutes  (sud- 
den collapse). 
In  Its  Chronic  Efifect. — Distress  in  the 
gastric  region;  chronic  catarrh  of  the 
stomach;  pyrosis;  pallid  countenance; 
catarrh  of  the  respiratory  tract;  lobular 
pneumonia;  headache,  vertigo,  insom- 
nia; gradual  emaciation  and  premature 
senescence. 

Chlorine  Acne. — (Occasioned  in  the 
electrolytic  production  of  chlorine  by 
chlorinated  carburetted  hydrogen.)  In- 
flammatory processes  in  the  dermal 
glands;  the  occurrence  of  unusually  dif- 
fuse, confluent  comedones  with  indu- 
rated, dark-green  heads;  solid  infiltra- 
tion of  the  sebaceous  follicles,  their  in- 
flammation and  suppuration  causing 
pustules  and  boils. 

Special  measures  of  relief:  Removal  of  the  patient  into  the  fresh  air;  inhalation  of  amyl  nitrite;  arti- 
ficial respiration;  on  account  of  the  paralyzing  effect  of  the  chlorine  on  the  heart,  stimulants  are  required 
(black  coffee,  subcutaneous  injection  of  camphorated  oil);  to  control  the  irritating  cough,  hypodermics 
of  morphine  or  cautious  inhalation  of  steam.  ,      ,        ,  n-         -j      r      ^u 

For  the  prevention  of  chlorine  acne:  Substitution  of  anodes  made  of  molten  metallic  oxides  tor  the  car- 
bon anodes. 


CHLORODINITRO- 
BENZOL,  CsHj- 
(N02)2C1:  Forming 
yellow  crystals.  (See 
Nitrobenzol.) 

CHLORONITRO- 
BENZOL,  C6H4N02- 
Cl:  Forming  yellow- 
ish crystals  of  aro- 
matic odor.  (See 
Nitrobenzol.) 


728        ETIOLOGY   AND    PROPHYL.\XIS    OF    OCCUPATIONAL   DISEASES 
List  of  Industrial  Poisons — Continued 


Designation  of 
the  substance 


Branches  of  Mode  of 

industry  in  which       entrance  into 
poisoning  occurs  the  body 


Absorption  by  The  chromates  act  very  much  hke  chromic 
the  skin  and  acid  itself;  pit-Hke,  phagedenic  ulcers, 
mucous  mem-  burrowing  deep  and  spreading  wide,  very 
branes;  in  the  difficult  to  heal  and  very  painful,  occur 
form  of  dust,  almost  exclusively  on  the  skin  of  the 
through  the  hands,  more  rarely  on  the  arms,  thighs', 
respiratory  or-  scrotum,  and  penis,  resembling  syphilitic 
gans.  ulcers;  they  also  appear,  though  seldom, 

on  the  mucous  membrane  of  the  tonsils 
and  of  the  hard  and  the  soft  palate.  With 
rare  exceptions  is  there  extension  of  the 
inflammation  to,  and  perforation  of,  the 
nasal  septum  at  the  cartilaginous  por- 
tion; eczematous  eruptions. 
Irritation  of  the  conjunctiva. 
Irritation  of  the  Bronchioles. — Chronic 
bronchial  catarrh,  and  small  areas  of  in- 
flammation in  the  lungs.  In  recent  years 
the  last-mentioned  symptoms  are  hardly 
ever  encountered  in  a  remarkably  wide 
field  of  observation.  It  is  at  least  ex- 
tremely doubtful  if  disease  of  the  kidneys 
is  ever  caused  by  chromium. 

In  handling  chromium  dyes  containing 
lead  there  is  danger  of  chronic  lead 
poisoning. 

Special  measures  of  relief:  Chromium  ulcers  are  successfully  overcome  by  careful  treatment  of  the 
slightest  injuries  to  the  skin,  and  by  the  immediate,  complete,  and  skillful  closure  of  the  lesions. 


CHROMIUM  COM- 
POUNDS :  Chromic 
acid,  anhydrous,  CrOa; 
chromates  and  bichro- 
mates, e.g.,  sodium 
chromate,  Na2Cr04; 
sodium  bichromate, 
NaiCrzOy;  lead  chro- 
mate, PbCrOj. 

Chromium  colors: 
Chrome  yellow  (acid 
chromate  of  lead) ; 
chrome  orange  (basic 
and  neutral  chromate 
of  lead);  chrome  red 
(c  h  r  o  m  e-cinnabar); 
acid  chromate  of  lead 
oxide  and  lead  hy-| 
drate;  chrome  green,  I 
poisonous  only  as  a| 
mixture  of  chrome 
yellow  and  paris  blue. 
{See  also  under  Lead.) 


Manufacture  of 
chromium  prepara- 
tions, chrome  col- 
ors, and  hectograph 
composition;  photo- 
graphy (color  and 
carbon  printing) ; 
oxidizing  agent  in 
the  tar-color  in- 
dustry; manufac- 
ture of  matches; 
wet  batteries; 
bleaching  fats,  oils, 
and  wax;  mordant 
in  Turkish  red  dye- 
ing, textile  printing 
(for  neutralizing 
colors  and  for  dye- 
ing); chrome  tan- 
ning (two-vat  proc- 
ess) ;  staining  of 
wood. 


Symptoms  of  poisoning 


In  the  form  of' Generally  speaking,  industrial  poisonings 
gas,  through  by  cyanogen  are  rare, 
the  respiratory  Acute  Poisoning. — ^Moderate  quantities 
organs;  prussic  of  the  gas  cause  vertigo,  headache,  rush 
acid  a  1  s  o!  of  blood  to  the  head,  oppression  of  the 
through  the  chest,  palpitation  of  the  heart,  a  sensa- 
epidermis.  1  tion  of  constriction  at  the  throat   with 

pharyngeal  irritation  and  dryness,  nausea 
and  vomiting,  difficult,  gasping  respira- 
tion, with  retention  of  consciousness. 
To  the  stage  of  dyspnoea  succeeds  that  of 
spasm  with  cold,  perspiring  skin,  convul- 
sions and  involuntary  micturition,  with 
loss  of  consciousness.  In  the  stage  of 
asphyxiation  there  are  temporary  sus- 
pension of  respiration,  retardation  of  the 
heart's  action,  lividity  of  the  skin  and 
mucous  membranes,  lowering  of  the  body 
temperature;  with  inhalation  of  large 
quantities,  the  stage  of  asphyxia  super- 
venes immediately.  Dilatation  of  the  pu- 
pils; loss  of  consciousness;  a  few  gasping 
inspirations;  cyanosis  of  the  skin  and 
mucous  membranes;  collapse;  death. 

Chronic  Poisoning  (very  doubtful).- — • 
Headache,  vertigo,  unsteadiness  of  gait; 
nausea,  loss  of  appetite,  disturbances  of 
the  gastric  and  intestinal  functions; 
slowing  of  the  pulse;  albuminuria. 

Special  measures  of  relief:  Fresh  air;  artificial  respiration;  administration  of  oxygen;  cold  afifusions 
and  friction;  hypodermatic  injection  of  ether,  camphor;  if  the  poison  has  been  taken  into  the  stomach, 
give  emetics,  then  immediately  rinse  out  that  viscus  with  water,  with  the  addition  of  one-quarter  to 
one-half  of  i  per  cent,  of  potassium  permanganate.  Kobert  recommends  a  3  per  cent,  solution  of  hydro- 
gen binoxide  for  subcutaneous  injection,  in  doses  of  i  cc.  at  different  points  in  the  body.  But  on  the 
other  hand,  H2O2  is  deemed  unsuitable,  and  an  alkaline  solution  of  ferric  sulphate  or  an  antidote  for 
arsenic  with  some  ferric  salt  is  indicated  as  the  best  remedy.  To  control  the  convulsions  give  morphia 
hypodermically. 


CYANOGEN  COM- 
POUNDS: Dicyano- 
gen,  C2N2;  prussic 
acid,  HCN:  Hydro- 
cyanic acid,  a  color- 
less, highly  volatile 
fluid,  of  penetrating, 
pungent,  and  irritat- 
ing odor. 

Natrium  cyanide 
(NaCN),  Cyanide  of 
potassium,  potassium 
cyanide,  (KCN):  A 
colorless  salt,  forming 
crystals  which,  after 
fusion,  recrystallize, 
but  readily  decom- 
poses on  exposure  to 
the  air,  setting  free 
hydrocyanic  acid. 
Rhodanic  (sulphocy- 
a  n  i  c  ,  SCN)  c  o  m- 
pounds :  Poisonous! 
dose  of  the  dilute  hy-l 
drocyanic  acid,  0.06  g 


Extraction  of  gold; 
silver  and  gold  plat- 
ing, galvanoplasty, 
electroplating;  man- 
ufacture of  cyano- 
gen compounds  and 
inorganic  processes 
(when  organic  re- 
sidue are  heated 
with  alkalies) ;  re- 
duction of  residuum 
to  gas;  blast  fur- 
naces; gas  works 
(purification  proc- 
ess), dye  works  and 
printeries;  photo- 
graphic establish- 
ments; manufacture 
of  celluloid. 


INDUSTRIAL   POISONS,    ETC. 
List  op  Industrial  Poisons — Continued 


729 


Designation  of 
the  substance 


Branches  of  Mode  of 

industry  in  which    ,    entrance  into 
poisoning  occurs  the  body 


Symptoms  of  poisoning 


DIAZOMETHANE,    In    methylizing    of  As  gas,  through  Acute    Poisoning. — Severe    headache; 

CH2XH:2:   a  very  vola-    every  kind.  the    lungs;    ef-   great    physical    depression;    grave   le- 

tile  yellow  gas.  !  feet      on      the   sions  of  the  lungs;  other    effects  like 


feet 
skin. 


those  of  dimethyl  sulphate. 


DIMETHYL    SUL-  Production     of    me-  In   the  form   of  Strongly   corrosive   eflFect  on   the  skin 
PHATE,  (CHshSOi:    thyl  ethers,  methyl    gas,    through   and  mucous  membranes;  burns;  pains 

A  colorless  oily  fluid.  esters    and    methyl    the  respiratory   in  the  nape  of  the  neck  and  in  the  thor- 

amines;      manufac-   organs;     direct   acic  cavity;  hoarseness;  destruction  of 
I  ture  of  artificial  per-;  action    on    the   the  mucous  membrane  and  aspiration 
fumes.  I  skin.  of  the  broken-down  products  mto  the 

I  lungs;     lachrymation,     conjunctivitis, 

,  formation     of     erosion-eschars,     and 
'  oedema,  photophobia  and  parenchyma- 
'  tous  clouding  of  the  cornea ;  even  coma, 

convulsions,  paralysis,  and  a  fatal  out- 
come. 


DINITROBENZOL  or 
BINITROBENZOL, 

C6H4(X02)2:  When  pure, 
crystallizing  as  slender, 
colorless,  rhombic 
needles;  when  impure, 
in  yellow,  crystalline' 
cakes.  (See  Nitro- 
benzol.) 


FO  R  MALD  EH  YD  E,  Disinfection;    manu- In  the  form   of  Intense    irritation    of    the    skin    and 
CH2O:  A  liquid,  volatil-   facture  of  many  or-    vapor,  through    mucous  membranes, 
izing  as  a  gaseous  vapor   ganic    preparations,    the  respiratory 
of  penetrating  odor;    10   especially      in     the   organs  and  mu- 


per  cent,  formaldehyde, 
formalin. 


coal-tar  color-indus-   c  o  u  s    mem 
try;  preserving  and    branes. 
hardening  of  human 
and     zoological 
preparations. 


Special  measures  of  relief :  Do  not  enter  the  disinfection  chamber  until  after  the  introduction  of  am- 
monia and  thorough  ventilation. 


HYDROCHLORIC 
ACID,  HCl:  Pure  HCl 
is  a  colorless  gas  that 
fumes  when  open  to  the 
air,  forming  a  dense, 
acid,  white  mist.  The 
crude  commercial  hy- 
drochloric acid  is,  for  the 
most  part,  impure,  con- 
taining arsenic  among 
other  admixtures. 


Treatment  with  chlo-  Action    on    the 
rine    of    previously   skin  and  nasal 
roasted    ores;     pot-    mucous     mem- 
teries  (glazing),   en-   brane;     seldom 
ameling  works,  glass   in    vaporous 
factories,  soldering;    form,    affecting 
in  the  chemical  in-   the  respiratory 
dustry,    manufac-   organs, 
ture  of  chloride  and 
sulphate  of  soda,  of 
muriatic  acid,  stan- 
nic    acetate,     etc.; 
manufacture  of  arti-        • 
ficial    fertilizers; 
bleaching,      shoddy! 
industry;    cotton-i 
print     works;     car- 
bonizing   of    mate- 
rials;    India-rubber 
industry.  I 


As  a  rule  the  rarefaction  of  the  hydro- 
chloric acid  gas  is  so  considerable  in  the 
industries  where  it  is  used  to  any  ex- 
tent worth  mentioning  that  only  in  ex- 
ceptional cases  do  injurious  effects 
occur,  such  as  irritation  of  the  respira- 
tory organs.  A  proportion  of  o.os  per 
mille  of  hydrochloric  acid  in  the  air  is 
well  borne,  but  only  for  a  short  time. 
A  greater  concentration  (as  well  as  the 
often-repeated  inhalation  even  of  mod- 
erate quantities  in  manufacturing  in- 
dustries) causes  chronic  irritation  of 
the  mucous  membranes  to  which  the 
vapor  has  access.  There  result  also 
catarrh  of  the  conjunctiva,  coryza, 
pharyngeal,  laryngeal,  and  bronchial 
catarrh,  together  with  dental  caries. 

Concentrated  HCl  vapor  may  cause 
unconsciousness  and  death. 


Special  measures  of  relief :  Removal  of  the  patient  from  the  dangerous  atmosphere;  inhalation  of  a 
finely  nebulized  solution  of  sodium  bicarbonate.* 


1  In  addition,  for  acute  poisoning,  give  atropine  (Ho  grain)  subcutaneously  to  stimulate  the  pneu- 
mogastric. — W.  H.  R. 


730        ETIOLOGY   AND   PROPHYLAXIS    OF   OCCUPATIONAL   DISEASES 
List  of  Industrial  Poisons — Continued 


Designation  of 
the  substance 


Branches  of  industry 

in  which  poisoning 

occurs 


Mode  of 

entrance  into 

the  body- 


Symptoms  of  poisoning 


HYDROFLUORICtProduction  in  chemical  In  the  form  of 
ACID  or  FLUORIC  works;  glass  factories,  gas,  through 
ACID,  HF:  A  color-'  etching  on  glass;  labora-  the  respiratory 
less  gas,  of  pungent'  tories  of  the  pottery  in-  organs.  In 
odor  and  forming  a  dustry;  extraction  of  the  fluid  state  it 
dense  mist  in  the  fluorides  of  antimony  has  an  immedi 
air.  I  (substitute     for     tartar   ate    action    on 

emetic    in    dye    works);    the     skin     and 
fertilizer    factories     (ex- 
traction of  phosphorites) 
bleaching    of    cane    for 
chair  seats  and  extraction  of  its  silicates 


Intense  irritation  of  the  eyelids  and 
conjunctiva,  coryza,  bronchial  catarrh 
with  spasmodic  cough,  ulceration  of 
the  nostrils,  gums,  and  oral  mucous 
membrane;  also  painful  ulcers  of  the 
cuticle,  erosions  and  formation  of 
vesicles;  suppuration  under  the  finger 
nails. 


mucous 
branes. 


LEAD,  Pb:  A  bluish- 
white,    highly    lus- 
trous  metal,   which 
on  exposure  to  the 
air  acquires  a  gray 
tarnish. 
Lead  alloys. 
Lead   colors;  other 
lead  compounds. 
Lead    Sulphuret 
(galena)  is  held  to 
be  non-poisonous, 
and  somelead  poly- 
silicates  are  regard- 
ed as  nearly  so. 


Absorption  of  Industrial  lead  poisoning  appears  as  a 
lead  and  lead  rule  in  the  chronic  form  and  arises  from 
compounds  oc-  continuous  absorption  of  the  most  in- 
curs: (i)  In  finitesimal  quantities  of  lead  during  a 
isolated  cases  protracted  period  of  time  (weeks, 
through*  the  months,  and  even  years), 
skin;  whether  The  beginning  is  insidious,  with  dis- 
through  the  turbances  of  the  general  health,  a  sense 
uninjured  skin  of  weakness,  decline  of  bodily  strength ; 
is  doubtful;  sallow,  pale-yellowish  hue  of  the  skin. 
(2)  in  the  form  Distress  in  the  region  of  the  stomach, 
of  vapor  (very  eructations,  lack  of  appetite,  metallic 
finely  divided  taste  in  the  mouth  and  fetid  breath, 
oxide  of  lead).  The  blue  line  (blue-gray  discolora- 
and  as  dust,  tion  of  the  gums)  which,  however,  may 
through  the  be  absent,  even  in  the  course  of  a  se- 
respiratory  or-  vere  attack;  lead  colic  with  most  obsti- 
gans;  (3)  by  nate  constipation,  retention  of  urine; 
way  of  the  di-  plumbic  arthralgia  (lacerating,  boring) 
gestive  tract  by  occurririg  for  the  most  part  paroxysm- 
means  of  con-  ally,  chiefly  in  the  lower  extremities, 
taminated  food  more  rarely  in  the  upper,  often  inter- 
and  drinks  (for  preted  as  a  symptom  of  rheumatism 
example, cigars,  of  the  joints;  frequently,  fibrillar  trem- 
cigaret'tes,  bling  of  the  fingers.  Typical  are  the 
chewing  tobac-  lead  paralyses,  of  which  disturbances 
co).  By  inhal-  of  sensation  (parsesthesia  and  anass- 
ation  the  dust,  thesia)  take  the  precedence.  Paraly- 
laden  with  lead,  sis  generally  affects  the  extensor  mus- 
finds  lodgment  cles  of  the  arm  and  hand,  with  atrophic 
in  the  upper  manifestations;  more  rarely,  the  flexor 
respiratory  muscles.  Sometimes  also  there  are 
tract,  and,  mix-  paralyses  of  the  estensors  and  flexors 
ed  with  saliva,  of  the  lower  extremities  or  muscles  of 
may  reach  the  the  shoulder.  From  experience  it  is 
stomach.  known  that  those  groups  of  muscles 

are  especially  affected  which  are  rnost 
used    in    the    occupational    activity. 
Transient  blindness,   but   also   gradu- 
ally     progressive     atrophy     of     the 
optic  nerve;  temporary  loss  of  the  special  senses  of 
smell  and  taste;  violent,  often  fatally  ending  disease 
of   the   brain    (saturnine   encephalopathy),   sometimes 
preceded  only  by  slight  premonitory  symptoms,  as  irri- 
tability and  headache,  ringing  in  the  ears,  insomnia; 
more  often,  slowly  increasing  mental  disturbances  pre- 
cede; epileptiform  convulsions,  hallucinations;  morbid 
changes  in  the  blood  vessels  and  of  the  heart  and  kid- 
neys  (contracted  kidney) ;  increase  of  blood  pressure 
and  granular  degeneration  of  the  red  blood  corpuscles. 
Disturbances  in  the  sexual  sphere  in  women;  abor- 
tion, premature  birth,  low  vitality  of  the  children. 

Measures  of  relief:  Discontinuance  of  work  in  lead  at  the  slightest  symptoms  of  lead  poisoning.  In 
lead  colic,  give  first,  by  the  mouth  or  subcutaneously,  morphia,  opium,  or  atropine;  afterward,  cath- 
artics (castor  oil  or  podophyllin);  in  paralysis,  electrical  treatment,  massage  and  baths;  in  every  case, 
strengthening  diet,  iodide  of  potassium,  and  sudorifics. 


Smelting  of  lead  and  lead- 
bearing  ores;  manufac- 
ture and  use  of  articles 
made  of  metallic  lead 
(sheets,  plates,  boxes, 
pipes,  wire,  cans,  flasks, 
pails,  kettles,  faucets,  re- 
torts) ;  manufacture  and 
use  of  lead  alloys,  as 
type  metal,  shot  (tin 
foil),  for  example,  in 
type  foundries,  tin  shops, 
bottle-cap  factories, 
composing  rooms,  file- 
cutting  works;  manufac- 
ture and  use  of  lead  col- 
ors and  other  lead  com- 
pounds,  as  litharge, 
white  lead,  Krems  white, 
red  lead,  lead  chromates, 
acetate  of  lead,  lead 
chloride  in  lead  color 
works  and  storage-bat- 
tery factories,  in  the 
trade  of  painter,  house 
painter  and  varnisher; 
plants  for  installation  of 
gas  and  water;  in  the 
ceramic  industry,  the 
textile  industry,  etc. 

It  is  to  be  observed  that 
materials  containing 
lead  may  occasionally 
be  employed  in  every  in- 
dustry, and  that  lead 
colors  and  other  lead 
compounds  are  often 
met  with  in  trade  under 
fanciful  names. 


INDUSTRIAL   POISOXS,    ETC. 
List  of  Industrial  Poisons — Continued 


731 


Designation  of 
the  substance 


Branches  of  Mode  of 

industry  in  which       entrance  into 
poisoning  occurs  the  body 


Symptoms  of  poisoning 


MANGANESE  DIOX- 
IDE, MnOj:  Brown  min- 
eral (occurring  chiefly 
as  pyrolusite). 


Breaking  and  grind-iln  the  form  of  MnOs  produces  cumulative  effects, 
ing  of  manganese  dust,  through  After  protracted  action  of  the  agent  the 
ore;  sifting  out  of,  the  respiratory  symptoms  begin  with  disturbances  of 
the  refuse.  organs.  the  general  sensibility,  general  debility, 

languor,  lancinating  pains  in  the  ex- 
tremities, in  the  small  of  the  back  and  nape  of  the  neck,  creeping  sensations 
.  in  the  legs  and  numbness  in  the  feet;  salivation;  tremor  of  the  head,  tongue, 
and  hands;  later,  locomotor  disturbances  with  uncertain,  stamping  gait,  and, 
ultimately,  the  impossibility  of  safe  and  sure  progression. 

Affections  of  the  voice  (low,  whispering)  and  of  speech  (indistinct,  scan- 
ning) combined  with  flatness  of  tone;  forced  laughter  and  weeping  and  low- 
ering of  intelligence. 
Sometimes  dropsical  effusion  into  the  cellular  tissue  of  the  lower  extremities. 


MERCURY,  Hg:  A  sil- 
ver-white, shining  metal, 
unchangeable  in  the  air, 
but  evaporating  at 
house  temperature. 
Mercury  compounds, 
amalgams  (alloys  with 
metals). 

Cinnabar  (HgS)  is  non- 
poisonous.  , 


Mining  and  smelting 
of  quicksilver;  oc- 
cupation of  mirror 
plater,  amalgam 
gilding  and  siiver- 
ing;  manufacture  of 
thermometers,  -ba- 
rometers, and  man- 
ometers, incandes-. 
cent  electric  lamps, 
Rontgen  and  Hit- 
torf  tubes,  mercurial 
vapor  lamps;  manu-' 
facture  of  the  salts' 
of  mercury,  amal-l 
gams,  and  colors.l 
pharmaceutic  prod-l 
ucts,  antiseptic 
dyes,  inflammablel 
materials,  and  ex-l 
plosives;  employ-' 
mercury,  especially 
ment  of  the  salts  of 
in  the  hare's  fur 
business  and  felt- 
h  a  t  manufacture; 
photography  and 
steel  engraving. 


Absorption  Industrial  mercurial  poisoning  is  a 
through  the  chronic  poisoning  occasioned  by  work 
uninjured  skin;  in  this  metal  for  a  long  period,  com- 
absorbed  in  the  monly  weeks,  months,  years,  or  dec- 
form  of  vapor  ades.  The  first  symptom  is  generally 
and  as  dust  increased  ptyalism,  with  swelling  and 
(amalgam  dust,  inflammation  of  the  gums  and  of  the 
dust  of  the  buccal  mucous  membrane,  often  with 
compounds  of  the  formation  of  rodent  ulcers,  besides, 
mercury).  there  are,  frequently,  disturbances  of 

digestion,  lassitude,   and  pallor.     As- 
sociated with  the  further  absorption  of 
mercury,    "erethism"     supervenes — a 
peculiar    psychic    excitability    (timor- 
ousness,     bewilderment,     irritability) 
aside  from  the  characteristic  mercurial 
j  tremor.     In  a  state  of  complete  repose 
this  tremor  is  not  noticeable,  and  man- 
ifests itself  only  on  voluntary  move- 
ment,   causing     a     quite    distinctive, 
irregular  tremulousness  of  the  fingers, 
hands,  arms,  and  finally,  also,  of  the 
legs  and  head.     In  strictly  chronic  cases  the  stomatitis 
and  erethism  are  absent,  and  only  the  tremor  is  observ- 
able.      Death  may  result  in  the  worst  cases  in  conse- 
quence of  the  violent  tremor  and  spasms  affecting  the 
entire     body;    in    other    cases,     increasing    weakness. 
Cachexia. 


Special  measures  of  relief:  Relinquishment  of  the  employment;  nutritious  diet;  vapor  baths;  potas- 
sium iodide. 


METHYL  ALCOHOL  Produced  by  the  dry  A  b  s  o  r  p  t  i  o  n 
(wood  spirit),  CH3OH:  distillation  of  wood;'  through  the 
A  colorless  fluid  of  faint   used  in  the  prepara-   digestive 


odor. 


tion  of  varnish,  lac-    g  a  n  s,    a  1  so 
quer,     polish,     and   through    the 
perfumes;     for    the   skin;    in    the 
denaturing   of  spir-    form  of  vapor, 
its;  for  the  produc-  through   the 
tion  of  coal-tar  col-    organs    of    res- 
ors  and  pharmaceu-   piration. 
tical     preparations; 
a  solvent  for  aniline 
dyes  in    cotton-print    manufacture; 
used  in  combination  with  shellac  for 
coating  the  interior  of  casks;  in  cabi- 
net making,  furniture  polishing  and 
paint  removing. 


The  effect  is  very  persistent;  nausea, 
headache,  ringing  in  the  ears,  weak- 
ness of  the  muscles,  insomnia,  delirium, 
difficulty  of  breathing,  and  sometimes 
deafness;  inflammation  of  the  throat 
and  the  mucous  membrane  of  the  air 
passages  extending  to  the  finest  rami- 
fications of  the  bronchial  tubes;  finally, 
death  by  paralysis  of  the  respiratory 
apparatus.  Conjunctivitis;  also  seri- 
ous affections  of  the  retina  and  the 
optic  nerve,  resulting  in  blindness, 
even,  from  atrophy  of  this  nerve.' 

In  chronic  cases,  fatty  degeneration 
of  the  liver  and  acidosis.* 


Special  measures  of  relief:  The  substitution  of  innocuous  media  for  methyl  alcohol  in  the  denaturing 
of  spirits. 


»  Permanent  blindness  and  even  a  fatal  issue  may  be  caused  by  the  ingestion  of  small  quantities  of 
wood  spirit;  hence  the  risk  incurred  in  using  cheap  essences  of  vanilla  and  other  flavoring  extracts 
which  contain  methyl  alcohol. — W.  H.  R. 

'J.  A.  M.  A.,  Oct.  2S.  1913.  page  1544- 


732        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 
Ltst  of  Industrial  Poisons — Continued 


^     .        ,.         (  Branches  of  Mode  of 

iJfsignation  ot  industry  in  which    .    entrance  into 

the  substance  |     poisoning  occurs  the  body 


Sj'mptoms  of  poisoning 


METHYL  BROMIDE,  Employed  in 
CHsBr:  A  colorless,  gas-  dye  factories 
eoui  body   of   aromatic 

odor. 
Methyl     iodide,     iodine 

methylate,    CH3I:       An 

ethereal,  colorless  fluid 
of  somewhat  penetrating 
odor,  soon  becoming  yel- 
low on  exposure  to  the 


aniline  In  the  form  of|In  mild  cases,  vertigo,  headache,  and 
gas,  through'  transient  stupor,  with  diplopia  and  a 
the  respiratory'  sensation  of  rigidity  in  the  muscles  of 
organs  and  the   the  eyes. 

mucous     mem-      In  a  severe  case  there  was  observed 
branes.  loss    of    consciousness    continuing    8 

weeks,  with  staring  look,  pallor  of  the 
skin,  retarded  pulse,  and  obstinate 
,  constipation.  During  brief  intervals 
of  wakefulness  there  was  unrest  with 
increasing     excitability.  (Grand- 

homme.) 


NITRANILINE,  C6H4- 
XHzXOs:  Forming 
long,  yellow  crystals. 
{See  Aniline.) 

NITROBENZOL  (mir- 
bane  oil.  imitation  bit- 
ter-almond  oil), 
C6H5NO2:  A  colorless, 
highly  refractive  fluid 
having  an  odor  like  that 
of  bitter  almonds;  and 
all  nitro-compounds  of 
benzol  and  its_  homo- 
logues,  e.g.,  dinitroben- 
zol,  dinitrochlorobenzol, 
nitrotoluol,  nitrophenol, 
nitronaphthalene,  etc. 
The  most  of  the  nitro- 
and  chloro-compounds 
are  the  more  poisonous. 


Coal-tar  color  indus-  (i)  Absorption  Poisoning  by  all  of  the  designated  sub- 
try  and  those  estab-  takes  place,  stances  is  pretty  nearly  the  same,  quali- 
lishments  in  which;  first  of  all,'  tatively;  quantitatively,  however, 
its  intermediate  through  the  differences  exist,  so  that  the  larger  pro- 
products  are  manu-  skin,  both  the  portion  they  contain  of  the  nitro  (NO2) 
factured,  as  in  ex-  uninjured  and  groups  the  more  virulent  they  are  like- 
plosives  works,  per-  especially^  thcj  ly  to  be.  The  nitrochloro-compounds 
fumery  and  soap  pathologically  are  very  much  more  dangerous  than 
factories,  pharma-  altered  skin,|  the  simple  nitro-compounds.  The  first 
particularly  ini  toxic  symptoms  may  appear  within  a 
the  case  of  pro-  few  hours  (8  to  24)  after  absorption  of 
fuse    perspira-i  the  poison. 

t  i  o  n  ;  (  2  )j  Acute  Poisoning. — (a)  In  mild  cases: 
through  the  Malaise,  headache,  giddiness,  nausea, 
respiratory  or-  loss  of  appetite,  costiveness,  burning 
gans;  (3)'  sensation  of  the  skin  and  mucous 
through    the   membrane. 


ceutical  laborator- 
ies, etc. 


digestive     or-      (b)  In  severe  cases:  AieelingoisinxietY, 
gans.  disturbances  of  sensation,  like  formi- 

cation on  the  legs  and  furriness  of  the 
soles  of  the  feet,  ringing  in  the  ears; 
disturbances  of  coordination  (reeling 
gait,  stammering  speech),  increased 
excitability  of  the  reflexes,  convulsions 
and  a  state  of  general  spasm;  later, 
with  decline  of  sensibility,  symptoms 
of  paralysis;  vomiting;  odor  of  the 
vomitus  and  of  the  exhaled  breath  like 
that  of  bitter-almond  oil;  icterus  of  the 
skin;  at  first  increased,  afterward 
diminished  activity  of  the  heart,  with 
lowered  tension  of  the  pulse;  visual 
derangements  (amblyopia,  optic  neu- 
ritis) ;  blood  viscid,  brown  to  deep  dun 
color;  diminution  of  the  red  corpuscles 
and  alterations  in  their  form;  in  the 
;  I  advanced    cases,    formation    of     met- 

hemoglobin.  The  course  of  severe  cases  is  exceptionally  varied;  after  inter- 
missions, exacerbations  may  occur  with  a  finally  fatal  result.  Death  may 
occur  also  in  connection  with  deep  insensibility,  without  other  sj'mptoms. 
The  symptoms  which  point  to  blood  changes  predominate,  in  severe  poison- 
ing, over  the  nervous  symptoms. 

Subacute  and  Chronic  Poisoning. — Icterical  skin,  which  gradually  be- 
comes cyanotic,  methemoglobin  formation;  symptoms  of  degeneration  and 
regeneration  of  the  red-blood  corpuscles;  general  debility,  anaemia.  The  clin- 
ical picture  is  similar  to  that  of  pernicious  anaemia.  In  the  urine  the  poi- 
soned corpuscles  are  sometimes  demonstrable,  and  finally  the  presence  of 
hematophorphyrin  and  of  albumen. 

Measures  of  relief:  Immediate  removal  from  the  workroom;  inhalation  of  oxygen;  artificial  respira- 
tion; eventually  bloodletting;  stimulants,  non-alcoholic;  prohibition  of  the  use  of  alcoholic  drinks  dur- 
ing working  hours;  avoidance  of^the  same,  also,  outside  of  employment. 


INDUSTRIAL    POISON'S,    ETC. 
List  of  Industrial  Poisons — Continued 


733 


Designation  of 
the  substance 


Branches  of  Mode  of 

industry  in  which    ,    entrance  into 
poisoning  occurs  the  body 


Symptoms  of  poisoning 


NITROGYLCERINE,  Manufacture  of  ex- Inhalation  of  the 
C3H603(X02)i, glycerine  plosives  (dynamite,  vapor;  absorp- 
trinitrate:  An  oily,  va-  nitro-cellulose) ;  in  tion  through 
porable,  colorless  fluid,  the  use  of  dynamite,  the  uninjured 
without  odor.  skin,    mucous 

membranes, 
I  and  wounds  of 
1  the   skin.     In 
the  explosion  of 
dynamite   the 
action    of    car- 
bon   dioxide 
and    nitrous 
\  monoxide,  as 
',  well  as  that  of 
j  undecomposed 
■  nitroglycerine 
is  present. 


Extraordinary  toxicity,  somewhat  like 
effects  of  prussic  acid;  just  a  few  drops 
are  deadly,  and  even  mere  contact 
with  products  containing  nitroglycer- 
ine may  cause  poisoning;  severe  head- 
ache, disturbance  of  the  intellect,  facile 
syncope,  vertigo,  burning  in  the  throat 
and  stomach;  nausea;  vomiting,  colic; 
symptoms  of  paraylsis  in  the  muscles 
of  the  head  and  eyes,  as  well  as  in  the 
lower  extremities;  bradycardia  and 
retarded  respiration,  stertorous  breath- 
ing and  dyspnoea;  cyanosis;  coldness 
of  the  extremities;  injection  of  the 
conjunctiva;  reddening  of  the  counte- 
nance. 

In  the  Tnixing  and  sifting  of  dynamite: 
Obstinate  ulcers  under  the  nails  and 
on  the  finger  tips,  eruption  on  the 
plantar  aspect  of  the  feet  and  inter- 
digital  spaces  of  both  hands,  with  ex- 
treme dryness  and  formation  of 
fissures. 

Explosion  of  nitroglycerine  with  little 
gas:  Trembling,  determination  of 
blood  to  the  head,  vomiting,  headache. 
Explosion  of  nitroglycerine  with  much 
gas:  Vertigo,  asphyxia,  cyanosis,  mo- 
tor paralysis  and  loss  of  consciousness; 
intermittent,  stertorous  respiration, 
coldness  of  the  skin,  small  pulse;  after 
recovery  of  consciousness,  debility, 
nausea,  vomiting,  headache,  inter- 
mittent pulse,  and  finally  death. 
Chronic  Poisoning. — Disturbances  of 
digestion,  trembling,  neuralgia. 


Special  measures  of  relief:  Absolute  avoidance  of  contact. 


NITRONAPHTHA- 
LENE,  Cii)H7(N02):  A 
yellow,  friable,  crystal- 
line mass  of  strongly  ar- 
omatic odor.  (5ee  Nitro- 
benzol.) 


734        ETIOLOGY   AND   PROPHYL^VXIS    OF    OCCUPATIONAL   DISEASES 
List  of  Ixdustrial  Poisons — Continued 


Designation  of 
the  substance 


Branches  of 
industry  in  which 
poisoning  occurs 


Mode  of 

entrance  into 

the  body 


Symptoms  of  poisoning 


NITROUS  GASES  (low 
degrees  of  oxidation  of 
nitrogen,  which  appear 
simultaneously) :  Nitro- 
gen protoxide,  NO;  ni- 
trogen deutoxide,  NO2; 
nitrogen  trioxide,  N2O3; 
anhydrous  nitrous  acid 
(H.NO2).  Red  fuming 
nitric  acid  is  a  saturated 
solution  of  N2O4  in  crude 
NHO3.  NO  is  a  color- 
less gas  which  under  the 
influence  of  atmospheric 
oxygen  is  readily  trans- 
formed into  brown  nitro- 
gen dioxide.  Below 
—  20°C.  N2O3  is  a  blue 
fluid;  at  the  ordinary 
temperature  it  separates 
into  NO  and  NO2. 


Nitrous    gases   are 
produced     by     the 
action  of  nitric  acid 
on  deoxidating  sub- 
stances   of    various 
kinds,     principally 
on    metals    (iron, 
lead,  zinc,  etc.),  on 
organic     substances 
(coal     dust,     wood, 
straw,    paper,    tex- 
tile    fabrics,     wool- 
en   refuse,    etc.)    as 
well  as  many  other 
substances  (pyrites, 
sulphurous    acid 
and   its   salts,    soda 
sediment,    hydro- 
choloric    acid,    iron 
chlorides,     sulphate 
of  iron,  etc.);  in  the 
preparation  of  nitric 
acid,    its    combina 
tions      and       salts, 
among  which  the  ni 
trous  salts  also  are 
to  be  included;  met 
al  etching  and  metal 
refining;  stamp  mills 
and  mints;  galvano- 
technics;      nitrifica- 
tion     in      chemical 
works     and     manu- 
factories   of    explo- 
sives; celluloid  man- 
ufacture;   sulphuric 
acid     manufacture; 
production  of  picric 
acid,  aniline  colors, 
nitrocellulose    (gun 
cotton,    collodion 
cotton),    xylcidine, 
nitro-starch,    nitro 
jute  dynamite,  abe^ 
lite,      nitromannite, 
n  i  tr  o  s  a  c  c  h  a  ro  s  e, 
viscosine,    etc.;    ni- 
tric   acid    manufac- 
ture    and     storage; 
preparations  of  tho- 
rium    and     cerium; 
bleaching   materials 
(oils,  etc.) ;  hat  mak' 
ing    (maceration    of 
the    hair) ;     etching 
and     engraving    on 
copper    (etching    of 
the    plate);    dyeing 
and    printing    (fixer 
and  mordant). 


In  gaseous  form,  Susceptibility  to  the  effects  of  nitrous 
through  the  gases  fluctuates  considerably.  Persons 
respiratory'  who  suffer  from  diseases  of  the  respira- 
oreans.  tory  organs  are  especially  susceptible; 

not  infrequently  the  continual  inhala- 
tion of  small  quantities,  for  many 
consecutive  years  even,  occasions  no 
serious  disturbances  of  the  health.  A 
pale,  sallow  complexion  and  chronic 
bronchial  catarrh  may  be  deemed, 
nevertheless,  the  usual  consequences 
of  occupational  inhalation  of  very 
moderate  quantities  of  nitrous  gases. 
Often,  however,  larger  quantities  of  the 
poisonous  gases  are  borne  for  hours 
together  (6  to  8  hours)  without  dis- 
comfort; when  suddenly,  after  a  long 
interval  without  disturbance,  ominous 
symptoms  appear. 

Symptoms  of  irritation  in  the  air 
passages  are  manifest,  as  a  feeling  of 
constriction  of' the  larynx,  spasmodic 
cough,  oppression  in  the  chest,  labored 
respiration,  anxiety,  cold  perspiration 
on  the  face,  protrusion  of  the  eyes, 
gasping  speech,  paroxysms  of  cough- 
ing, bluish  discoloration  of  the  coun- 
tenance, coldness  of  the  extremities. 

Consciousness  is  at  first  unimpaired, 
but  with  increasing  difficulty  of 
breathing  it  becomes  dimmed;  injury 
to  the  teeth.  The  urine  is  scanty, 
brown  in  color,  containing  hemoglobin 
and  albumen.  Death  results  from 
oedema  of  the  lungs.  In  very  severe 
cases  methemoglobin  is  observed,  and 
then  a  general  systemic  poisoning  may 
result. 


Special  measures  of  relief:  Immediate  removal  from  the  noxious  atmosphere;  inhalation  of  oxygen; 
hnally,  bloodlettmg  and  mfusion  of  normal  salt  solution. 


INDUSTRIAL   POISONS,    ETC. 
List  of  Industrial  Poisons — Continued 


735 


Designation  of 
the  substance 


Branches  of 
industry  in  which 
poisoning  occurs 


Mode  of 

entrance  into 

the  body 


Symptoms  of  poisoaing 


OXAXIC  ACID,  CiRiOt:  Manufacture  of  ox-  In  the  form  of  Opalescent  or  bluish  discolorations 
It  forms  large,  pellucid  alic  acid;  polishing  dust,  through  (with  brittleness)  of  the  nails;  blood 
crystals.  of  metals,  especially   the  respiratory   stasis  in  the  hands;  corrosive  action  on 


of  copper  and  brass  organs, 
utensils;  used  in  dye 
works,  chemical 
cleansing  plants 
(rust  a  n  d  i  n  k 
stains) ;  straw  hat 
manufacture  and 
straw  braiding. 


the  mucous  membrane  of  the  oesopha- 
gus, of  the  stomach  and  bowel;  weak- 
ness   of    the    heart;    convulsions    and 

{  spasms. 

I  However,  industrial  poisonings  by 
oxalic  acid  are  exceedingly  rare. 


PETROLEUM:  A  mix-  Production  of  oil;  re-  In  the  form  of  The  vapors  of  petroleum  cause  a  pro- 
ture  of  various  hydro-  fining  of  the  crude  vapor,  through  found  acute  poisoning  with  a  condi- 
carbons  of  the  methane,  oil;  furniture  polish-  the  respiratory  tion  of  inebriation;  shouting,  reeling, 
ethyl,  and  aromatic  ing  by  use  of  so-  organs.  As  a  and  prolonged  sleep  without  any  rccol- 
series.  called  polishing  oil.     fluid  it  has  a  di-   lection    of    what    has    happened;    in 

rect   action   on  severe    cases,    loss    of    consciousness, 
the  skin.  lividity   of   the   countenance,    staring 

look  and  contracted  pupils,  almost  im- 
perceptible pulse,  asphyxia.  The 
chronic  effect  of  petroleum  vapor 
causes  numbness  and  irritation  of  the 
Schneiderian  membrane. 

In  general,  the  symptoms  of  the  ac- 
tion of  petroleum  resemble  those 
resulting  from  the  action  of  benzine. 
By  reason  of  the  high  boiling  point  of 
petroleum  there  are  produced,  in  the 
extraction  of  paraffine  butter,  in  the 
emptying  of  retorts,  and  in  the  filling 
of  casks  with  petroleum,  obstinate  in- 
flammations of  the  hand  in  the  form 
of  acne  (nodules,  pustules,  and  boils). 

Special  measures  of  relief:  Removal  into  the  fresh  air;  in  collapse,  a  tepid  bath  with  cold  affusions; 
subcutaneous  injections  of  camphorated  oil. 


PHENOL,  C2H5OH  (car- Anthracite  coal  tar  Action  on  the  Erosion  of  the  skin,  which  by  great 
bolic  acid):  A  white  distillation;  produc-,  epidermis  and  extension  may  lead  to  severe  internal 
crystalline  mass,  and  its   tion    of    picric    acid;  the      digestive  injuries;    symptoms    of    degeneration 


homologues,  e.g.,  cresol, 
lysol,  and  their  deriva- 
tives. 


and  of  many  organ- j  tract, 
ic  aromatic  com- 
pounds; used  in 
dyeing,  calico  print- 
ing; manufacture  of 
lampblack,  in  pho- 
togen  factories;  im-  , 
pregnating  wood 
with  tar  and  oil  of 
tar;  surgical  dress- 
ing industry. 


in  the  blood  and  in  the  internal  organs 
(nephritis);  gangrene,  icterus,  collapse. 


PHENYLHYDRAZINE,  A  by-product  in  the  Absorption     byjObstinate    vesicular    eruption    on    the 
CeHsXHNHs:     A     yel-    manufacture  of  an-;  the  skin;  action  j  skin,  with  itching  and  burning;  diar- 
tipyrine    from    ani-j  on  the  skin.  rhea,    loss    of    appetite;    granular   de- 

line;  manufacture  of  j  generation    of    the    blood    corpuscles; 

organic  compounds.  formation  of  methemoglobin;  a  sense 

of  general  malaise. 


lowish.  oily  fluid,  shad- 
ing into  brown,  of  pun- 
gent color. 


736        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 
List  of  Industrial  Poisons — Continued. 


Designation,  of 
the  substance 


Branches  of  Mode  of 

industry  -in  which    I    entrance  into 
poisoning  occurs     !        the  body 


Symptoms  of  poisoning 


PHOSGENE,    COChjIn  the  manufacture 


(carbon  oxychloride) :  A 
colorless  gas,  of  suffocat- 
ing odor. 


In  the  form  of  Until  the  present  time  only  the  acute 
of  phosgene  and  its  vapor,  through  form  of  poisoning  has  been  recognized, 
use  for  the  produc-  the  respiratory  The  first  symptoms  of  illness  some- 
tion  of  organic  com-    organs.  times  appear  only  after  many  hours, 

pounds.  By    means    of    the    hydrochloric    acid 

arising  from  the  decomposition  of  the 
gases  in  the  lungs,  destruction  of  lung 
tissue  results,  with  difficulty  of  breath- 
ing, paralysis  of  the  lungs,  and  pul- 
monary oedema.  A  fatal  outcome  is 
often  observed. 

Special  measures  of  relief:  Inhalation  of  oxygen  and  medical  attendance  immediately  after  breathing 
the  phosgene  gas. 


PHOSPHORUS,  P:  A  Extraction  of  phos-lln  the  form  of  As  industrial  poisoning  it  occurs  only 
colorless,  transparent  phorus  from  phos-  vapor,  through'  in  the  chronic  form,  occasioned  by  the 
substaiicej    on    exposure    phorites     and    cop-    the  respiratory!  absorption  of  very  minute  particles  of 


to  the  light,  translucent   rolites,     bone-black    organs;  into  the 
and  of  a  yellowish,  waxy    (refuse    of    sugar   digestive  canal 
luster.       In  the  air  it  is    mills),    bone-ash   by     means     of 
luminous,    and    when:  (refuse  of  meat  ex-   food     contami- 
heated    in    closed    ironl  tract  manufacture);,  nated     by     the 
crucibles  to  a  tempera- 1  production  of  phos-   fingers;     action 
ture  ranging  from   250°;  phor-b  r  o  n  z  e,    o  f  j  on  the  skin, 
to  300°C.  it  is  converted!  phosphorus    c  o  m-| 
into   red    or   amorphous    pounds,    igniting! 
phosphorus,  which  is  un-,  agents,    matches 
affected  by  the  air.    The    and  tar  colors, 
yellow    or    white    phos- 
phorus  is    very    poison- 
ous; the  red,  non-poison-| 
ous 


the  poison  for  a  period  of  months,  gen- 
erally, indeed,  of  years.  Symptoms  of 
the  disease  sometimes  first  appear 
long  after  relinquishment  of  the  occu- 
pation. 

It  is  doubtful  whether  chrohic  phos- 
phorism  occurs  (that  is,  general  sys- 
tematic poisoning  by  phosphorus). 

Chronic  phosphorus  poisoning  uni- 
formly affects  the  bones  of  the  face, 
beginning  with  inflammation  and 
sclerosis  of  the  bones  and  of  the  peri- 
osteum; then,  by  extension  of  the  sup- 
purative process,  necrosis  results. 
This  most  frequently  attacks  that 
portion  of  the  alveolar  process  of  the 
jawbone  which  is  least  protected 
against  infection. 

Swelling  and  ulcerations  on  the  gums 
and  the  buccal  mucous  membrane, 
pain  even  in  the  sound  teeth,  loosen- 
ing and  falling  out  of  the  teeth,  infil- 
tration of  board-like  hardness  occurs 
in  the  soft  parts  surrounding  the  jaw; 
suppuration  and  destruction  of  the 
jawbone  (necrosis)  with  numerous  fis- 
tulous channels  which  here  and  there 
burrow  through  the  cheek.  Hand  in 
hand  with  the  ulcerative  processes  go 
osteoplastic  formations,  so  that,  while 
suppurative  destruction  of  tissue  takes 
place  at  one  point,  at  another  the 
formation  of  new  bone  is  going  on. 
The  under  jaw  is  more  often  affected 
than  the  upper;  here  the  process  goes 
on  insidiously  without  formation  of 
new  bone  but  with  local  destruction 
of  the  part.  The  palatal  and  orbital 
bones  may  be  attacked  with  ulcera- 
tion and  shrinking  of  the  eyeball.  By 
extension  of  the  inflammation  along 
the  sheaths  of  the  vessels  there  result 
meningeal  inflammation  and  cerebral 
abscess. 

There  is  remarkable  brittleness  of 
the  bones,  decline  of  appetite,  pallid 
complexion,  diarrhea,  emaciation. 
Sometimes  there  is  amyloid  degenera- 
tion of  the  abdominal  organs.  Death 
by  sepsis. 


^u^^t  '"««•'«''«•?  of  relief:  To  the  utmost  possible  extent  the  prohibition  of  the  use  of  white  or  yellow 
pnosphorus;  exclusion  of  laborers  that  have  dental  caries,  after  extraction  of  a  tooth  at  least  2  weeks' 
!!!»offi'°"  !?"^i  .  employment;  change  of  occupation;  improvement  of  the  general  health;  there  is  no 
speciiic  medical  treatment;  in  appropriate  cases,  operative  intervention. 


INDUSTRIAL   POISONS,    ETC. 
List  of  Industrial  Poison-s — Continued 


737 


Designation  of 
the  substance 


Branches  of         '        Mode  of 
industry  in  which       entrance  into 
poisoning  occurs  the  body 


Symptoms  of  poisoning 


A  grayish  yellow,  odor- 
less and  tasteless  sub- 
stance. 


PHOSPHORUS  SES-Tn  chemical  f  a c-  Inhalation  of  Irritation  of  the  mucous  membranes. 
QUIbULPHipt,     Foba:   tones.  sulphuretted    especially     obstinate      conjunctivitis. 

hydrogen  in  the  Through  the  influence  of  dust  in  the 
fusion  of  phos-  grinding  and  sifting  of  the  composi- 
phorus  and  sul-,  tion  there  appear  symptoms  of  CSt 
phur  as  well  as  poisoning.  To  be  noticed  also  is  the 
in  the  drawing  danger  of  poisoning  by  sulphuretted 
off  of  the  molt-  hydrogen.  {Ste  under  Sulphuretted 
en    mass    from   hydrogen.) 

the    kettles;    dust    in    grinding    and 

sifting   of   the   paste;   bicarburet   ofi 

sulphur  vapors  in  the  extraction"  ofj 

yellow  phosphorus  and  regeneration 

of  CS2.  I 

Special  measures  of  relief :  Prevention  of  the  contamination  of  phosphorus  sesquisulphide  with  yellow 
phosphorus;  precautions  against  injury  from  the  effects  of  sulphuretted  hydrogen. 


PHOSPHURETEDIn  the  extraction  of  In  the  form  of 
HYDROGEN,  PH3:  A  phosphorus;  in  the  gas,  through 
colorless  gas  of  nauseat-  preparation  of  red  the  respiratory 
ing  odor.  phosphorus  and  the   organs. 

sesquisul  p  h  i  d  e    o  f  1 

phosphorus;  in  the 

reduction     of    iron 

silicate     containing! 

phosphorus   by   the| 

action  of  moisture; 

in     the    production: 

of     acetylene     with 

calcium    carbide' 

that  contains  an  ad-! 

mixture   of  calcium 

phosphate. 


An  anxious,  oppressed  feeling  in  the 
chest,  changing  to  a  burning,  lan- 
cinating pain;  affections  of  the  head, 
vertigo,  tinnitus  aurium;  general  de- 
bility; loss  of  appetite;  great  thirst. 
Death  occurs  without  convulsions, 
through  the  effect  of  the  poison  on  the 
blood. 


PICRIC  ACID,  C6H2Chemical  works,  In  the  form  of  Poisonings  with  picric  acid  are  rare; 
(OH)(X02)3:  Trinitro-  dye-houses;  manu-  dust,  through  when  they  occur  there  are  itching;  in- 
phenol  in  a  pure  state  facture  of  explosives  the  respiratory  fiammation  of  the  skin,  vesicular  erupH 
forms  pale-yellow,  bitter  and  powder  (lydd-  passages;  di-  tion,  yellow  pigmentation  of  the  epi- 
tasting,  fohate,  metallic    ite,    melinite);    pro-   rect    action   on   dermis  and  of  the  conjunctiva,  inflam 


crystals. 


jectile  factories,  fill-,  the  skin. 
ing  shops. 


mation  of  the  buccal  mucous  mem- 
brane, bitter  taste,  disturbances  of 
digestion,  epigastric  pain,  nausea, 
vertigo,  diarrhea,  and  jaundice;  picric 
acid  decomposes  the  constituents  of 
the  blood. 

By  the  penetration  of  dust  into  the 
nostrils,  sneezing  and  nasal  catarrh 
are  occasioned. 


PYRIDINE,  CsHsN:  A, In  its  manufacture  In  the  form  of  Catarrh  of  the  mucous  membranes; 
colorless  fluid  of  pun-  out  of  coal  tar  and  vapor,  through  hoarseness,  irritation,  and  choking 
gent    and    characteristic   bone  tar;  in  the  use   the  respiratory   sensation  in  the  throat;  headache,  ver- 


odor.       Its  homologues,!  of   denaturing   spir- 
pyridine  bases.  its  (shops  for  wood- 


organs.     In     a   tigo,   flaccidity  and  trembling  of  the 
fluid     state     it   extremities;    difficulty    of    breathing 


working,  gilding,   acts  on  the  skin  and  clonic  convulsions;  eczema  of  the 
and    hat    manufac-   of    the    hands  hands. 

ture).  •  and  arms.  Industrial  poisoning  by  pyridine  is 

very  rare. 


SULPHUR  CHLORIDE,  Solvent  for  sulphur  In  the  form  of  In  contact  with  water  and  atmospheric 
S2CI2:  A  thickish  fluid,!  and  fats;  caout-  vapor,  through  moisture,  it  is  resolved  into  hydro- 
of  brownish  color  and'  chouc  and  patent  the  respiratory  chloric  acid  vapor.  The  vapor  of 
suffocating  odor,  fuming   rubber  industry.  organs.  sulphur  chloride  is  suffocating;  if  in- 

on  exposure  to  the  air.    i  ,  gested,  it  excites  vomiting. 

Special  measures  of  relief :  Wearing  of  rubber  gloves;  instant  removal  of  the  patient  from  the  poison- 
ous atmosphere. 


47 


738        ETIOLOGY   AND   PROPHYLAXIS    OF   OCCUPATIONAL   DISEASES 
List  of  Industrial  Poisons — Continued 


Designation  of 
the  substance 


Branches  of 
industry  in  which 
poisoning  occurs 


Mode  of 

entrance  into 

the  body 


Symptoms  of  poisoning 


SULPHUR  DIOXIDE, 
SULPHUROUS 
ACID,  (H2SO3):  Its 
anhydride  is  SO2,  in 
the  form  of  gas;  con- 
densed, it  becomes 
fluid.  The  gas  is  of 
pungent  odor  and  suf- 
focating effect. 


Roasting  of  sulphur- 
bearing  ores;  brick 
works,  ceramic  indus- 
try; manufacture  of 
sulphuric  acid,  of  ul- 
tramarine; extraction 
of  bones,  manufacture 
of  glue  and  gelatine 
from  bones;  disinfec- 
tion; refining  of  petro- 
leum; manufacture  of 
candles;  bleaching  of 
wax,  silk,  and  wool; 
chromium  tanning 
t w o-v at  process); 
bleaching  of  straw 
hats  and  bristles;  pre- 
serving wine  and 
fruits ;  fumigating  hopsj 
and  casks  with  _  sul-i 
phur;  ice  machines; 
heating  plants  (burn- 
ing of  pyrite-bearing 
coal. 


In  the  form  of 
gas,  through 
the  respiratory 
organs. 


In  moderate  concentration  sulphurous 
acid  is  borne  without  inconvenience  or 
injury;  persons  accustomed  to  the  gas 
bear  very  well  a  proportion  of  0.003 
to  0.004  per  cent,  of  SO2  in  the  air._ 

Susceptible  persons,  at  the  beginning 
of  their  employment  in  an  atmos- 
phere containing  sulphurous  acid, 
manifest  a  transient  irritation  of  the 
mucous  membrane  of  the  respiratory 
organs  and  of  the  eyes. 

In  its  severe  action  there  is  spas- 
modic cough  with  secretion  of  tena- 
cious, often  blood-tinged,  mucus. 
The  protracted  effect  of  a  high  degree 
of  concentration  is  livid  discoloration 
of  the  mucous  membranes,  bronchial 
catarrh,  croupous  angina  of  the  bron- 
chi and  their  branches,  and  inflamma- 
tory ar^as  in  the  lungs;  disturbances 
of  digestion. 


Special  measures  of  relief :  Removal  from  the  noxious  atmosphere;  admission  of  fresh  air;  artificial 
respiration;  infusion  of  weak  alkaline  solutions  (0.05  to  o.i  per  cent,  liquor  natrii  caustici  Isolulion  of 
caustic  soda]). 


SULPHURETTED  Blast  furnace  plants, 
HYDROGEN,  orin  granulating  the  slag ; 
HYDRIC  SUL-  distillation  of  sulphur 
PHIDE,  H2S:  A  color-  waters;  ultramarine 
less  gas,  having  the  works;  Leblanc  soda 
fetid    odor    of    rotten    and    chemical    factor- 


In  the  form  of 
gas,    through 

the  respiratory 
organs,  as  pure 
hydric  sulphide 
gas;  often 
found  in  admix- 
ture with  other 
gases  (with 
CO2,  N,  NH4, 
and  carburetted 
hydrogen);  di- 
rect action  on 
the  c  o  n  j  u  n  c 
tiva. 


eggs.  les;    in   the    manufac- 

ture of  the  compounds 
of  sulphur  and  phos- 
phorus ;  sulphur  metals 
(manufacture  and  use) ; 
sulphide  of  soda  and 
sulphide  of  barium  in- 
dustry (manufacture 
of  sulphide  colors  and 
dyeing  with  these) ; 
the  extraction  of  cellu- 
lose (straw  and  wood); 
in  the  waste  waters  of 
industries  which  make 
use  of  organic  sub- 
stances; sedimenta- 
tion tanks  of  sugar 
works;  precipitation 
of  soda  residua  con- 
taining calcium  sul- 
phide; work  in  sewers, 
latrines,  and  dung 
pits;  illuminating-gas 
plants;  flan— retteries;: 
tanneries.  | 

Special  measures  of  relief :  Before  emptying  of  dung  pits  and  the  like,  their  contents  should  be  thor- 
oughly mixed  with  iron  sulphate  (5  kg.  pro  i  cbm.);  the  emptying  should  be  effected  by  mechanical 
apparatus;  safety  ropes  to  be  attached  to  the  workmen;  prompt  hoisting  out  of  the  unconscious  work- 
men; removal  of  the  soiled  clothing;  artificial  respiration;  acfministration  of  oxygen;  hypodermics' of 
ether  or  camphor. 


Acute  Poisoning. — In  the  less  violent 
cases  there  are  gastric  distress,  nau- 
sea, fetid  eructations,  irritation  and 
inflammation  of  the  conjunctiva; 
rarely,  erosion  of  the  cornea,  forma- 
tion of  vesicles  on  the  lips,  irritating 
cough,  headache,  and  a  sensation  of 
giddiness.  In  long-continued  inhala- 
tion convulsions  and  paralyses  occur. 

In  severe  cases  there  are  contraction 
of  the  pupils,  slowing  of  the  pulse, 
Cheyne-Stokes  respiration,  nystagmus, 
trismus,  and  tetanus. 

With  a  very  high  proportion  of  sul- 
phuretted hydrogen  in  the  air  a  man 
suddenly  falls,  becomes  unconscious 
and  dies  without  convulsions  (apo- 
plectic form). 

Chronic  Poisoning. — Conjunctival 
catarrh;  a  sense  of  pressure  in  the  head 
and  on  the  chest;  headache,  debility, 
vertigo,  nausea,  disturbances  of  diges- 
tion; sallow  complexion  and  emacia- 
tion; slowing  of  the  pulse;  tendency  to 
the  formation  of  boils. 


INDUSTRIAL   POISONS,   ETC. 

List  of  Industrial  Poisons — Concluded 


739 


Designation  of 
the  substances 


Branches  of 
industry  in  which 
poisoning  occurs 


Mode  of 

entrance  into 

the  body 


Symptoms  of  poisoning 


SULPHURIC  ACID,  Manufacture  of  sul-Hn  the  form  of 
H2SO4:  A  colorless,  odor-;  phuric  acid;  accu-!  vapor,  through 
less,  thick,  oily,  fluid.       1  mulator    factories!  the  respiratory 


(mould  and  charging 
rooms) ;  burnishing 
of  iron,  steel,  etc.; 
textile  industry,  hat 
factories;  petroleum 
distillation;  facto- 
ries for  the  manu- 
facture of  powdered 
fertilizers. 


organs. 


Inflammatory  disease  of  the  respira- 
tory organs  (acute  and  chronic  ca- 
tarrh), inflammation  of  the  lungs; 
anorexia;  decalcification  of  the  bones 
(according  to  Lewin);  injury  to  the 
teeth  through  softening  of  the  dentine. 
As  a  result  of  the  bespattering  of  the 
skin  with  concentrated  HsSO*  there  is 
severe  pain,  a  whitish  discoloration 
of  the  skin,  becoming  brownish,  with 
reddening  and  swelhng  of  the  sur- 
rounding tissues;  in  cases  of  extensive 
scalds  there  are,  ultimately  decompo- 
sition of  the  blood,  formation  of  ulcers, 
of  the  duodenum,  somnolence,  and 
even  death. 


TAR:  A  product  obtain- 1  Manufacture  of  illu- 
ed  by  dry  distillation,!  niinating  gas;  coke 
particularly  of  anthra-1- ovens;  tar  works; 
cite  coal  and  lignite.  [  tar-product  facto- 
ries; plants  for  wood 
preserving;  manu- 
facture of  roofing 
paper;  use  for  con- 
crete paving;  paint- 
ing of  metals;  as  a 
fuel;  briquet  facto- 
ries. 


TURPENTINE    OIL: 

A  mixture  of  various 
terebinthine  hydrocar- 
bons, CioHu,  differing 
in  odor  and  in  composi- 
tion according  to  the 
botanical  species  from 
which  they  are  severally 
derived. 


It  acts  on  the!  Tar  itch  under  the  form  of  diffuse  acne, 
skin;  in  thei  eczema  or  psoriasis,  primarily  on  the 
form  of  vapor,  I  upper  extremities,  later,  also,  on  the 
on  the  respira-  other  parts  of  the  body;  not  infre- 
tory  organs.  quently  on  the    irritated   portions  of 

the  skin  there  appear  cancroid  ulcers, 
especially  of  the  scrotum  (among 
chimney  sweepers,  paraffine  and  soot 
workers  and  briquet  makers). 

Together  with  the  effect  on  the 
greater  portion  of  the  skin,  there  are 
also  general  symptoms:  Loss  of  appe- 
tite, nausea,  diarrhea,  headache, 
numbness,  vertigo,  besides  disturb- 
ances of  the  urinary  bladder  (ischuria, 
strangury),  also  albuminuria  and 
oedema. 


Manufacture  of  var- 
nish, cement,  lac- 
quer, sealing  wax, 
colors;  tapestry 
printing;  trade  of 
decorator,  lacquer- 
er  and  house  paint- 
er; as  a  cleansing  a- 
agent  in  various 
industries. 


In  the  form  of  Irritation  of  the  mucous  membrane  of 
vapor,  it  actSi  the  eyes,  of  the  nose  (coryza),  and  of 
upon  the  mu-j  the  upper  air  passages  (hemming, 
c  o  u  s  mem-  cough,  bronchial  inflammation) ;  sali- 
branes;  in  vation;  besides  there  are  insensitive- 
fluid  state,  it  ness,  giddiness,  headache, 
acts  on  the  epi-  Prolonged  action  of  the  oil  causes 
dermis.  irritation    of    the    kidneys,    and    then 

these  organs  excrete  urine  having  the 
odor  of  violets. 

Severe  irritation  of  the  skin  is  ex- 
cited, especially  by  the  so-called  pine 
oil  (Russian  oil  of  turpentine). 


740        ETIOLOGY   AND   PROPHYL.\XIS    OF   OCCUPATIONAL   DISEASES 

List  of  Industries  in  Which  Poisoning  May  Occur* 


Branches  of  industry  in  which  poisoning 
may  occur 


Designation  of  industrial  poison 


Abelite,  manufacture  of 

Accumulator,  electrical,  works 

Acetate  of  lead,  manufacture  of 

Acetylene  production  (if  calcium  carbide  contams 

admixture  of  calcium  phosphate) 
Acids,  commercial  manufacture  of 
Acid,  hydrochloric,  manufacture  of 
Acid,  hydrofluoric,  manufacture  of 
Acid,  muriatic,  manufacture  of 
Acid,  picric,  manufacture  of 
Acid,  stearic,  manufacture  of 
Acid,  sulphuric,  manufacture  of 
Acid,  valeric,  manufacture  of 
Air  pollution 
Alcohol,  denatured 
Alkaloids,  manufacture  of 
Amber  workers 
Amalgam 

Ammonia  salts,  manufacture  of 
Ammunition,  manufacture  of 
Amid  compounds  of  benzol,  etc. 
Amyl  nitrite,  manufacture  of 
Anatomical  preparations 
Aniline  color  dye  factories:  Aniline  orange,  auran- 

tia,  saffron  yellow.  Manchester  yellow,  Meldola 

dyes,    corvulin,    Bismarck    blue,    indulin,   fast 

black 
Antimony  alloys,  and  extraction  of 
Antiseptic  dressing,  manufacture  of 
Antipyrine,  manufacture  of 
Arsenic  acid,  manufacture  of 
Arsenic  mining 
Arsenical  ores,  smelting 
Artificial  flowers  and  leaves 
Artificial  ice  and  cold  storage 
Asphalt,  testing 
Aurantia  dyes 
Automobilists 
Babbiting  metal,  and  solder 
Bakers  and  confectioners 
Balloon  filling  with  impure  hydrogen  gas 
Barium  sulphide,  maniifacture  of 
Barometers,  manufacture  of 

Batteries,  storage,  dry,  manufacture  of 

Batteries,  storage,  wet,  manufacture  of 

Beet  sugar,  manufacture  of 

Benzine  plants 

Benzol 

Bicycles,  manufacture  of 

Bismarck  blue,  manufacture  of 

Bismuth,  manufacture  of 

Black  aniline  colors 

Blacksmiths 


Blast  furnace  workers 

Bleacheries 

Bleaching  agents,  manufacture  of 

Bleaching  agents,   for  bristles,   cane,   silk,   straw 

hats,  wax  and  wool 
Bleaching  agents  for  cotton,  linen  and  paper 
Bleaching  agents  for  cane  and  extraction  of  its 

silicates 
Bleaching  agents  for  fats,  oil  and  wax 
Bone  ash,  refuse  of  meat  extract 
Bone-black,  refuse  of  sugar  refineries 
Bone-black,  manufacture  of 
Bone,  extraction  of 
Bone,  rendering  plants 
Bone  tar,  manufacture  of 
Bookbinders 
Boot  and  shoe  industry 
Bottle  caps  and  capsules 
Box  and  card  factories 
Brasiers 
Brass  etching 


Nitrous  gases. 

See  Batteries,  storage. 

Lead. 

>  Phosphureted  hydrogen. 

Arsenic. 

Hydrochloric  acid. 

Hydrofluoric  acid. 

Hydrochloric  acid. 

Picric  acid. 

Acrolein. 

Nitrous  gases,  sulphur  dioxide. 

Amyl  alcohol. 

Carbon  dioxide,  carbon  monoxide. 

Benzol,  methyl  alcohol,  pyridine. 

Benzol. 

Lead. 

Mercury. 

Ammonia. 

Acrolein,  antimony,  lead  (see  also  "Explosives"). 

Aniline. 

Amyl  alcohol. 

Formaldehyde,  phenol. 

Aniline,      arseniureted      hydrogen,      antimony, 

>  hydrochloric  acid,  methyl  bromide, 
nitrobenzol,  nitrous  gases. 

Antimony,  lead. 

Mercury,  phenol. 

Benzine,  phenylhydrazine. 

Arsenic,  arseniureted  hydrogen. 

Arsenic 

Arsenic 

Arsenic,  lead. 

Ammonia. 

Carbon  disulphide. 

Aniline  dyestuffs. 

Carbon  monoxide,  benzine. 

Lead. 

Carbon  dioxide,  carbon  monoxide. 

Arseniureted  hydrogen. 

Sulphureted  hydrogen. 

Mercury. 

f  Benzol,  creosote,  hydrochloric  acid,  sulphuric 
\    acid,  lead,  mercury,  pitch,  zinc  chloride. 

Chromium  compounds. 

Ammonia,  sulphureted  hydrogen. 

Benzine. 

Benzol. 

Amyl  acetate. 

Aniline  dyestuffs. 

Arsenic. 

Aniline  dyestuffs. 

Acrolein,  carbon  monoxide,  cyanogen  compounds. 
(  Carbon  monoxide,  cyanogen  compounds,  lead 
I  fumes,  if  lead  is  present  in  iron  ore,  sulphur 
I  dioxide,  sulphureted  hydrogen  (in  granulating 
i    slag). 

Chlorine,  sulphur  dioxide. 

Nitrous  gases. 

!  Sulphur  dioxide. 
I  Chloride  of  lime. 

I     \  Hydrofluoric  acid. 

[    Chlorine,  chromium  compounds. 
I    Phosphorus. 
!    Phosphorus. 

Ammonia,  phosphorus. 

Sulphur  dioxide. 

Acrolein,  benzine. 

Pyridin. 

Carbon  monoxide,  methyl  alcohol. 

Benzine,  methyl  alcohol,  lead,  mercury. 

Lead. 

Arsenic,  chrome  and  lead  compounds. 

Carbon  monoxide. 

Arsenic  chloride. 


'Arranged  by  Geo.  M.  Kober,  M.  D. 


INDUSTRIAL   POISONS,    ETC. 
List  of  Industries  and  Poisons. — Continued 


741 


Branches  of  industry  in  which  poisoning 
may  occur 


Designation  of  industrial  poison 


Brass  instruments,  musical 

Brass  foundries 

Brass  polishing 

Brass  lacquer 

Breweries,    fermentation  rooms 

Breweries,  fumigation  of  vats,  and  disinfection 

Breweries,  shellacing  casks 

Brick  kilns,  brick  and  tile  makers 

Briquet  factories  for  fuel 

Britannia  metal 

Bronze  workers 

Bronzing  with  nitrate  of  mercury 

Brown  mineral  mills 

Brunswick  green 

Brush  makers 

Bullets,  dipping 
Bullets,  manufacture  of 
Burnishing  of  iron  and  steel 
Cable  wire,  manufacture  of 
Cabinet  makers 

Caoutchouc  solvent  and  refining  of 
Caisson  work 
Calcining  dolemite,  etc. 

Calico  printing 

Candles,  manufacture  of 

Cane  factories 

Canning  industry 

Carbolic  acid 

Carbonated  waters 

Carbon  chloride,  manufacture  of 

Carbon  sulphurate,  manufacture  of 

Carbonizing  of  materials 

Carpet  cleaning 

Carpet  dye 

Cassel  green 

Celluloid  manufacture 

Cellulose,  extraction  from  straw  and  wood 
Cements 

Ceramic  industry 

Cerium,  preparation  of 

Chair  factories,  polishing 

Chalk,  colored 

Charcoal  burning 

Chemical  cleansing  establishments 

Chemical  cleansing  removal  of  ink  and  rust  stains 


Chemical  industry 

Chloride  of  lead 

Chloride  of  lime,  manufacture  of 

Chlorinating  process 

Chlorine,  organic  products 

Chloroform  manufacture 

Chromate  of  lead 

Chromate  tanning 

Chromium  colors  and  preparations 

Chromo-lithography 

Christmas  ornaments,  manufacture  of 

Chrysoidin  fast  black,  manufacture 

Church  crosses,  gilding 

Cinnabar 

Cleaning,  dry 

Coal  mines 

Coal  oil 

Coal-tar  anthracite  distillation 


Lead. 

]'  Antimony,     benzine,    carbon    dioxide,     carbon 

•1    monoxide,   lead,  phosphorus,  sulphur  dioxide, 

[    zinc  fumes. 

Lead,  oxalic  acid,  sulphuric  acid. 
Amyl  acetate,  methyl  alcohol. 
Carbon  dioxide. 
Sulphur  dioxide,  zinc  oxide. 
Methyl  alcohol. 

(  Carbon  dioxide,  carbon  monoxide,  sulphur  diox« 

\    ide,  lead  glaze. 
Tar. 

Antimony. 

Antimony,   lead,  zinc,  arsenic,  acids,  phosphorus. 
Mercury. 
Manganese. 
Arsenic. 

I  Anthrax,    lead,    methyl    alcohol,    tar    (see    also 

1  Bleaching). 
Acrolein. 
Antimony,  lead. 
Antimony,  sulphuric  acid. 
Carbon  disulphide,  lead. 
Aniline  stains,  chrome  lead  stains. 
Benzol,  carbon  disulphide,  sulphur  chloride. 
Carbon  dioxide.  • 

Carbon  dioxide,  carbon  monoxide. 

f  Aniline,  chromium,  cyanogen  and  chlorine  com- 

■J    pounds,  hydrochloric  acid,  lead,  methyl  alcohol, 

[    phenol,  antimony,  arsenic,  carbon  monoxide. 
Sulphur  dioxide. 

/  Aniline  stains,  chlorine,  chloride  of  lime,  hydro- 

1    fluoric  acid,  methyl  alcohol,  sulphur  dioxide. 

Carbon  monoxide,  lead,  acid  fumes,  sulphur  dioxide. 

Phenol. 

Carbon  dioxide. 

Carbon  disulphide. 

Carbon  disulphide. 

Acid  fumes  and  arseniureted  hydrogen. 

Benzine. 

Arsenic. 

Arsenic. 

f  Acetaldehyde,  aniline  and  lead  colors,  cyanogen 

■j    compounds,  methyl  alcohol,  nitrous  gases,  sul- 

I    phureted  hydrogen. 
Nitrous  gases,  sulphureted  hydrogen. 
Turpentine,  benzine. 

I  Hydrofluoric  acid,  lead,  sulphur  dioxide  (see  also 

\    Potteries). 
Nitrous  gases. 

f  Methyl    alcohol,    petroleum    (see    also    Rattan 

\    Industry). 
Arsenic. 

Carbon  monoxide. 
Benzine,  benzol. 
Oxalic  acid. 

f  Ammonia,  aniline,  carbon  disulphide,  chlorine, 
cyanogen  compounds,  hydrochloric  acid,  methyl 

\    compounds,    nitrous   gases,    nitrobenzol,    phos- 

I    phorus    sesquisulphide,     picric     acid,     sulphur 

[    dioxide,  carbon  monoxide,  etc. 
Lead. 

Chlorine,  arseniureted  hydrogen. 
Chlorine. 
Chlorine. 
Chloride  of  lime. 
Chomium,  lead. 

Chromium  compounds. 

Chromium  compounds. 

I  Arsenic,  brass,  chromium,  lead,  nitrous  gases  in 

\    etching,  turpentine. 

Arsenic. 

Aniline  dyestufls. 

Mercury. 

Mercury. 

Benzine,  benzol. 

Carbon  dioxide,  carbon  monoxide  (see  mining). 

Petroleum. 

Phenol,  pyridine,  tar. 


742         ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 
List  of  Industries  and  Poisons — ContUiued 


Coal-tar  color  industry 

Cochineal 
Coke  ovens 
Collodion  cotton 
Commercial  acids,  impure 

Colors,  manufacture  of  for  paints,  etc. 

Colored  chalk 
Colored  lights 
Colored  paper 
Colored  pencils 

Combs,  horn-celluloid 

Compositors 

Concrete  paving 

Coopers 

Copper  plate  etching  and  engraving 

Copper  polishing 

Copper  smelting 

Copper  workers 

Corvuline  dye 
Cowper  apparatus 
Creasote,  cresol 
Cumol 

Cutlery  industry 

Decorators  and  painters 

Decomposition  gases 

Denaturing  of  spirits 

Dentists 

Deoxidating  processes 

Diamond  cutting  aiid  setting  of  precious  stones 

Dinitrobenzol,  manufacture  of 

Dinitrochlorobenzol,  manufacture  of 

Dinitro-compounds,  manufacture  of 

Dip  for  scabby  sheep 

Disinfection 

Distilleries 

Dolemite  calcining 

Drying  processes  by  means  of  open  fires 

Dung  pits 

Dyes,  antiseptic 

Dyes,  organic,  manufacture  of 

Dyestuffs 

Dyeing  and  printing,  fixer  and  mordant 

Dyeing  and  dye  works 


Dynamite,  manufacture  of 

Electrical  accumulator  works 

Electric  lamps,  manufacture  of 

Electric  lamps,  incandescent  wire 

Electric    line    workers. 

Electric  meters. 

Electroplating. 

Electrotyping 

Emery  wheels,  babbitting  of 

Enamelling  works 

Engraving,  steel 

Essences,  fruit,  artificial 

Etching  on  brass 

Etching  on  metals 
Ether,  methyl 
Ethyl  violet 
Extraction  of  antimony 
Extraction  of  bone 
Extraction  of  gold  and  silver 

Explosives,  manufacture  of 


Aniline,   formaldehyde,    methyl   alcohol,   nitro- 
benzol,  nitrous  gases. 
Arsenic. 

Ammonia,  carbon  monoxide,  tar. 
Nitrous  gases. 
Arsenic. 

f  Benzine,  benzol,  chromium  compounds,  arsenic. 

\    lead,  mercury,  turpentine. 
Arsenic. 

Arsenic,  antimony. 
Arsenic,  chromium,  lead  compounds. 
Aniline  dyestuffs. 
Acetaldehyde,  acid  fumes,  aniline,  lead  colors   (see 

also  Celluloid). 
Lead,  antimony,  arsenic,  benzine. 
Tar. 

Methyl  alcohol  shellac. 
Nitrous  gases. 
Oxalic  acid. 
Arsenic,  carbon  monoxide,  sulphur  dioxide. 

f  Arseniureted    hydrogen,   lead,    nitric     and    sul- 

\    phuric  acid  fumes. 
Aniline  dyestuffs. 
Carbon  monoxide. 
Phenol. 
Benzol. 

Carbon  monoxide,  acid  fumes,  lead  (see  also 
Brass,  Tempering,  Tinning). 

Arsenic,   benzine,   chromium   compounds,   lead, 
mercury,  methyl  alcohol,  turpentine. 
Ammonia,  carbon  dioxide,  sulphureted    hydrogen. 
Methyl  alcohol,  pyridine. 
Mercury. 
Nitrous  gases. 
Lead,  carbon  monoxide. 
Nitrobenzol. 
Nitrobenzol. 
Nitrobenzol. 
Arsenic. 

I  Carbon    disulphide,    chlorine,  chloride   of   lime, 
cyanogen   compounds,  formaldehyde,    mercury 
bichloride,  phenol,  sulphur  dioxide. 
Carbon  dioxide,  sulphureted  hydrogen,  sulphur 
dioxide. 
Carbon  dioxide,  carbon  monoxide. 
Carbon  monoxide. 
Ammonia,  sulphureted  hydrogen. 
Mercury. 
Acridine. 

/  Ammonia,    chloride    of    lime    (see    also  Aniline 

1     Dyestuffs). 
Nitrous  gases. 

Antimony,  arsenic,  aniline  dyestuffs,  benzol, 
chromium  compounds,  cyanogen  compounds, 
hydrofluoric  acid,  phenol,  oxalic  acid,  picric  acid, 

i    sulphuretted    hydrogen  (dyeing    with    sulphide 

1  _  colors),  ammonia,  lead,  methyl  alcohol. 
Nitrous  gases,  nitroglycerine. 
See  Batteries. 
Lead,  mercury. 
Amy!  acetate. 
Carbon  monoxide,  solder. 
Mercury,  lead  (see  also  Brass  Industry). 
Cyanogen  compounds. 

Antimony,  arsenic,  lead,  carbon  monoxide. 
Lead. 

Hydrochloric  acid,  lead,  benzine,  carbon  monoxide. 
Mercury. 
Amyl  alcohol. 
Arsenic  chloride,  nitrous  gases. 

f  Arseniureted  hydrogen,  mercury,  nitrous  fumes, 

\    chlorine,  phosphoric  acid. 

Dimethyl  sulphate. 

Aniline  dyestuffs. 

Antimony. 

Sulphur  dioxide. 

Cyanogen  compounds,  mercury. 

{  Aniline  dyestuffs,  mercury,  nitrous  gases,  nitro- 

\    benzol,  nitroglycerine,  picric  acid. 


INDUSTRIAL    POISONS,    ETC. 
List  of  Industries  and  Poisons — Continued 


74.S 


Branches  of  industry  in  which  poisoning 
may  occur 


Designation  of  industrial  poison 


Farmers 

Fats,  bleaching  of 

Fats,  extraction  of 

Fats,  solvents 
Faucets,  brass,  polishing 
Feathers,  ornamental 
Fermentation  rooms 

Felt-hat  industry 

Ferrosilicon 

Fertilizers,  artificial  manufacture  of 

File  cutting 

Fireworks 

Firearms,  manufacture  of 

Firemen 

Flasks,  manufacture  of 
Flax  retteries 
Flowers,  artificial 
Foundries,  iron 
Fluoric  acid 
Fluorides,  extraction  of 
Fruit  essences,  manvifacture  of 
Fruit,  dried,  preservation 
Fuel  briquet  factories 
Fumigation  casks,  hops,  fruit 

Furnace  gases 

Furniture  factories,  staining  and  polishing 

Furriers 

Galvano-plasty 
Galvano-techniques 

Galvanizing  with  zinc  or  tin 

Garage  workers 
Garbage  fat  extraction 
Gardeners 
Garment  workers 

Gas  plants 

Gas  and  steam  fitters 

Gas  machines 

Gas  purification 

Gasoline 

Gelatine  manufacture 

Gilding  and  silvering 

Glass  etching 

Glass  factories 

Glass  polishing 

Glaze  mixing  and  dipping 

Glove  and  mitten  manufacture 

Glove  cleaning 

Glucose,  manufacture  of 

Glue,  manufacture  of 

Glycerine,  trinitrate 

Gold,  extraction  of 

Gold  plating 

Grease  removal 

Gums,  solvent  for 

Gun  cotton 

Gunsmiths 

Hair  industry 

Hardening  and  tempering  steel   magnets,   piano 

wire,  springs,  files,  etc. 
Hat,  felt,  factory 

Hat,  straw,  factory 
Heating  and  power  plants 
Hectograph  composition 
•  Hides  and  skins 
Hittorf  tubes 


Carbon  dioxide  in  Silos.    See  also  insecticides 

Chromium  compounds. 

Benzine,  benzol,  acrolein,  carbon  disulphide. 

I  Benzol,   benzine,   carbon  disulphide,  sulphur 

\    chloride. 

Lead. 

Benzine. 

Carbon  dioxide. 
Mercury,    methyl    alcohol,    nitrous   gases,    sul- 
phuric acid,  nitric  acid,  arsenic  dyestuffs,  carbon 
monoxide. 

Arseniureted  and  phosphureted  hydrogen. 

J  Hydrochloric  acid,  hydrofluoric  acid,    sulphuric 

\    acid,  sulphureted  hydrogen,  benzine. 

Lead. 

Antimony,  arsenic,  carbon  monoxide,  phosphorus. 

Antimony,  carbon  monoxide,  nitrous  gases. 

I   Benzine,  carbon  monoxide,  nitrous  and  other 

[     acid  fumes. 

Lead. 

Sulphureted  hydrogen. 

Arsenic,  lead. 

Carbon  monoxide,  sulphuric  acid. 

Hydrofluoric  acid. 

Hydrofluoric  acid. 

Amyl  alcohol. 

Sulphur  dioxide. 

Tar. 

Sulphur  dioxide, 
f  Carbon    monoxide,   sulphur   dioxide     (see    also 

1    Blast  Furnaces). 
Aniline,  arsenic,   chrome  stains,  lead,  methyl  al- 
cohol, petroleum,  phenol,  turpentine. 
Lead  for  dyeing;  mercury  and  nitrous  gases  fo 
rabbit  fur,  arsenic,  anthrax. 

Cyanogen  compounds. 

Nitrous  gases. 

f  Ammonia,  arseniureted  hydrogen,  hydrochloric 
1    and  sulphuric  acids,  zinc. 

Benzine,  carbon  monoxide. 

Benzine. 

See  Insecticides. 

j  Aniline  and  arsenic  dyes,  carbon  monoxide  from 

\    ironing  stoves,  lead  from  weighted  silk. 

)  Ammonia,    carbon    monoxide,  cyanogen    com- 

\    pounds,  tar. 

Arseniureted  hydrogen,  lead,  nitrous  gases. 

Carbon  monoxide. 

Carbon  monoxide,  cyanogen  compounds. 

Benzine. 

Sulphur  dioxide. 

Mercury. 

Hydrofluoric  acid. 

(  Arsenic,    hydrofluoric   acid,   hydroch^ric   acid 

\     chromium  compounds,  carbon  monoxide,  lead, 

[    manganese,  phenol  (see  also  Painters). 

Lead. 

Lead. 

Anthrax, acids, aniline,  chrome  and  lead  compounds. 

Benzine. 

Arsenic  from  impure  sulphuric  acid. 

Sulphur  dioxide,  chloride  of  lime. 

Nitroglycerine. 

Cyanogen  compounds,  mercury. 

Cyanogen  compounds. 

Benzine,  benzene,  carbon  disulphide. 

Carbon  disulphide. 

Nitroglycerine,  nitrous  gases. 

Antimony,  cyanogen  compounds,  carbon  monoxide. 

Anthrax.  .  ,      . 

Acrolein,  cyanogen  compounds  and  lead. 

/  Mercury,    methyl    alcohol,    nitrous    gases,    suU 
I    phuric  acid,  arsenic,  dyestuffs,  carbon  monoxide. 

Sulphur  dioxide,  methyl  alcohol,  oxalic  acid. 

Carbon  dioxide,  carbon  monoxide. 

Chromium  compounds,  aniline. 

Anthrax,  arsenic,  sulphur  dioxide(see  alsoTanning) . 

Mercury. 


744        ETIOLOGY   AND   PR0PHYL.4XIS    OF    OCCUPATIONAL   DISEASES 
List  of  Industries  and  Poisons — Continued 


Branches  of  industry  in  which  poisoning 
may  occur 


Designation  of  industrial  poison 


Hydrochloric  acid 
Hydrogen  gas 

House  painting 

Ice  machines 
Igniting  agents 

Illuminating  gas,  manufacture  of 

Imitation  bitter-almond  oil 

Imitation  silk  factories 

Imperial  yellow  dye,  manufacture  of 
Impregnated  wood 

Incandescent  electric  light 
India-rubber  industry 


Indian  white  fire 

Indulin  dye,  manufacture  of 

Ink  stains,  removal  of 

Insecticides,  manufacture  and  use  of 

Insulated  wire,  manufacture  of 
Iodine,  manufacture  of 
Iron  chloride,  sulphate,  manufacture 
Iron,  deoxidation  of 

Iron,  galvanizing  with  zinc  or  tin 

Iron  silicate,  impure,  decomposition  of 

Iron  sulphate,  manufacture  of 

Ironing 

Iron  sanitary  ware 

Iron  and  steel  workers 


Jewelry,  manufacture  of 

Kaiser  green 
Krems  white 
Lace  workers 

Lacquer  manufacture 

Lampblack,  manufacture 
Lamp  shades,  coloring  purposes 
Lanolin,  extraction  of 
Lard  making 
Latrines 

Laundries 

Lead  alloys 

Lead  colors 

Lead,  deoxidation  of 

Lead  metal 

Lead  smelting 

Lead  plating 

Leaf-metal  workers 

Leather  industry 

Leather  sole  stitching 

Leather  patent 

Leblanc  soda,  manufacture 

Ligroine 

Lime  chloride,  manufacture  of 

Lime  kilns 

Linoleum,  manufacture  of 

Linotyping 
Litharge 

Lithographing 

Litho;transfer  work 
Lyddite,  manufacture  of 
Lysol 


Nitrous  gases. 
Arseniureted  hydrogen. 

f  Arsenic,   benzine,   lead,    chrome   colors,   methyl 

\    alcohol,  turpentine. 
Ammonia,  sulphur  dioxide. 
Phosphorus. 

f  Ammonia,    benzol,    carbon    monoxide,    carbon 

1    disulphide,  sulphureted  hydrogen,  tar. 
Nitrobenzol. 

f  Carbon  disulphide,  ammonium  sulphide,  nitrous 

\    fumes. 
Aniline  dyestuffs. 
Phenol,  tar. 

iAmyl  acetate,  carbon  monoxide,  mercury, 
methyl  alcohol.^ 
Aniline  oil,  antimony,  benzine,  benzol,  carbon 
disulphide,,  cinnabar  (rnercury) ,  hydrochloric 
acid,  lead,  sulphur  dioxide  and  chloride,  tar, 
wood  alcohol. 
Arsenic. 

Aniline  dyestuffs. 
Oxalic  acid. 

f  Arsenic,    carbon   disulphide,    cyanogen    and 

\    mercury  compounds,  sulphur  dioxide. 
Carbon  disulphide,  lead. 
Benzol. 
Nitrous  gases. 
Nitrous  gases. 

I  Ammonia,    arseniureted   hydrogen,    acid   fumes 

\    and  zinc. 

Arseniureted  and  phosphureted  hydrogen. 
Arseniureted  hydrogen. 
Carbon  monoxide,  chlorine,  arsenic 
Carbon  monoxide,  lead,  acid  fumes. 

f   Carbon  monoxide,  other  furnace  gases  (see  also 

1     Cutlery  Industry). 

f  Ammonia,  amyl  acetate,  cyanogen  compounds, 
lead    solder,  hydrochloric,  nitric  and  sulphuric 
acids,  mercury,     carbon    monoxide    (see    also 
Brass). 
Arsenic. 
Lead. 
Carbon  monoxide. 

{  Ammonia,  amyl  acetate,  benzine,  benzol,  methyl 

\    alcohol,  turpentine. 
Phenol. 
Arsenic. 

Carbon  disulphide. 

Acrolein,  ammonium  sulphide,  acid  fumes. 
Ammonia,  sulphureted  hydrogen. 

[  Benzine,  benzol,  chlorine,  aniline  colors  for  mark- 

\    ing  ink,   carbon  monoxide,  arsenic  from  coke- 

(    burning  ironing  stoves. 
Antimony,  copper,  tin,  etc. 
Lead. 

Nitrous  gases. 
Arsenic. 

Antirnony,  arsenic,  lead,  sulphur  dioxide. 
Arseniureted  hydrogen. 

/  Ammonia,  amyl  acetate,  acetone,  benzine,  benzol, 

\    methyl  alcohol,  turpentine. 

Arsenic,  chromium  compounds,  lead,  mineral  acids 
Mercury. 

Amyl  acetate,  benzine,  methyl  alcohol. 
Sulphureted  hydrogen. 
Benzine. 
Chlorine,  arseniureted  hydrogen. 

I  Carbon     dioxide,     carbon    monoxide,    sulphur- 
dioxide. 
Acrolein,  amyl  acetate,  arsenical,  mercurial  and 
lead  pigments,  benzine  and  turpentine,  manga- 
nese, zinc  oxide. 
Antimony,  arsenic,  lead,  organic  vapors. 
Lead. 

f  Arsenic,  acid  fumes,  bronze  powder,  aniline.Jben- 
\    zine,  turpentine. 
Lead. 

Picric  acid. 
Phenol. 


INDUSTRIAL   POISONS    ETC. 
List  of  Industries  and  Poisons — Continued 


745 


Branches  of  industry  in  which  poisoning 
may  occur 


Manchester  yellow,  manufacture  of 

Manganese  mills 

Manumeters.  manufacture  of 

Marble  polishers 

Masonic  white  leather  aprons 

Mattress,  manufacture  of 

Matches,  manufacture  of 

Meldola  dyes 

Melinite,  manufacture  of 

Mercury  compounds,  manufacture  of 

Mercury  mimng 

Mercury  smelting 

Mercury  vapor  lamps 

Metal  dipping 

Metal  burnishing 

Metal  etching 

Metal  lacguer 

Metal  polishing 

Metal  refining 

Meters,  electric,  manufacture  of 

Methyl  amines 

Methyl  esters 

Methyl  ether 

Methyl  violet 

Methylizing  of  every  kind 


Mining 


Mineral  water,  carbonated 
Mints 
Mirbane  oil 
Mirror  plating 

Mirror  silvering 

Moulds,  drying 
Monotyping 

Moulding,  picture-frame  manufacture 

Mordant  in  dyeing 

Mosaic  works 

Muriatic  acid 

Muslin  green,  color 

Naphtha,  naphthol  nitrates 

Naphthalein 

Navy 

Nickel  buffers  and  polishers 

Nickel  platers 

Neuwied  green 

Nitric  acid  manufacture,  salts  and  storage 

Nitrite  of  amyl 

Nitrificating  in  chemical  works 

Nitrobenzol 

Nitrocellulose 

Nitroglycerine 

Nitrojute 

Nitromannite 

Nitronaphthalene 

Nitrophenol 

Nitrosaccharose 

Nitroso  dyes 

Nitrotoluol 

Op,  bleaching  of 

Oil,  solvent 

Oilcloth,  manufacture  of 

Oil,  vitreol 

Open-fire  heating 

Organ  builders 

Organic  dyes,  manufacture 

Organic  preparations,  manufacture 

Oxalic  acid,  manufacture  of 

Oxygen,  manufacture  of 

Painters  and  commercial  artists 

Paper  deoxidation 
Paperhangers 


Designation  of  industrial  poison 


Aniline  dyestuffs. 
Manganese. 

Mercury. 

Lead. 

Lead. 

Anthrax,  infectious  diseases. 

Chromium  compounds,  phosphorus. 

Aniline  dyestuffs. 

Picric  acid. 

Mercury. 

Mercury. 

Mercury. 

Mercury. 

Acid  fumes. 

Antimony,  acid  fumes. 

Arseniureted  hydrogen,  nitrous  fumes,  mercury. 

Amyl  acetate. 

Oxalic  acid. 

Nitrous  gases. 

Mercury,  lead  (see  also  Brass  Industry). 

Dimethyl  sulphate. 

Dimethyl  sulphate. 

Dimethyl  sulphate. 

Aniline  dyestuffs. 

Diazomethane. 

Arsenic,  carbon  dioxide,  carbon  monoxide,  lead, 
mercury,  nitroglycerine,  nitrous  fumes,  sulphur- 
eted  hydrogen,  and  other  gaseous  pioducts  of 
combustion  of  e.xplosive  compounds. 

Carbon  dioxide. 
Nitrous  gases. 
Nitrobenzol. 
Mercury. 

f  Acetaldehyde,  ammonia;  lead,   if   backed   with 

\    red  lead. 

Carbon  monoxide. 

Antimony,  arsenic,  acrolein,  lead. 

I  Amyl  acetate,  bronze,  methyl  alcohol  (see  also 

\    Leaf-metal  Workers). 
Antimony,  chromium  compounds,  etc. 
Manganese. 
Hydrochloric  acid. 
Arsenic. 

Benzine,  benzol,  nitrous  gases. 
Aniline,  aniline  dyestuffs. 

Carbon  monoxide,  gun  firing,  and  furnace  rooms. 
Lead,  nickel-carbonyl. 
Benzene,  lime,  nickel  salts,  petroleum. 
Arsenic. 
Nitrous  gases. 
Amyl  alcohol. 
Nitrous  gases. 
Aniline,  nitrous  gases. 
Nitroglycerine,  nitrous  gases. 
Nitrous  gases. 
Nitrous  gases. 
Nitrous  gases. 
Nitrobenzol. 
Nitrobenzol. 
N;trous  gases. 
Aniline  dyestuffs. 
Nitrobenzol. 

Chromium  compounds,  nitrous  gases. 
Benzine,  carbon  disulphide. 

f  Acrolein,  amyl  acetate,  arsenical  and   lead  pig- 
\    ments. 
Sulphuric  acid. 
Carbon  monoxide. 
Lead,  bronze,  methyl  alcohol. 
Acridine,  arsenic. 

Formaldehyde,  phenylhydrazine,  phosgene. 
Oxalic  acid. 
Chloride  of  lime. 

Arsenic,  benzine,  benzol,  lead,  mercury,  methyl 
alcohol,  tar,  turpentine,  phenol,  amyl  acetate, 
carbon  disulphide. 
Nitrous  gases. 
Arsenic,  lead. 


746        ETIOLOGY   AND   PROPHYLAXIS    OF    OCCUPATIONAL  DISEASES 
List  of  Industries  and  Poisons — Contimt,ed 


Branches  of  industry  in  which  poisoning 
may  occur 


Designation  of  industrial  poison 


Paper  mills 

Paraffine  refining 
Paris  green 
Parrot  green 
Paving  material 
Pencils,  colored 
Percussion  caps 
Perfumes,  manufacture  of 

Petroleum  industry,  distillation  and  refining 

Pharmaceutical  preparations 

Phenol  nitrates,  manufacture  of 

Phenylhydrazine,  manufacture  of  and  its  use  for 
production  of  organic  compounds 

Phosgene,  manufacture  of  and  its  use  for  pro- 
duction of  organic  compounds 

Phosphor  bronze 

Phosphorus  extraction  from  phosphorites  and 
coprolites 

Phosphorus,  manufacture  of 

Phosphorus,  red,  manufacture  of 

Phosphorus,  sesquisulphide,  manufacture  of 

Phosphorus  and  sulphur  compounds 

Photoengravers 

Photogen  factories 

Photographing  establishments,  material 

Physical  apparatus,  manufacture  of 
Pianos,  manufacture  of 

Picric  acid  manufacture 

Picture  frames,  manufacture  of 

Plumbers 

Polish  for  furniture 
Polish  for  metals 
Porcelain  enamelled  ware 

Potteries 

Printing  establishments 

Preservative  fluid  for  animal  tissues 

Preservative  for  wood 

Projectiles,  manufacture  of,  filling  shops 

Putty  making 

Putrefaction  processes,  gases  of 

Pyridin,  manufacture  of 

Pyrites 

Pyrotechniques 

Quicksilver 

Rabbit  fur  for  felt  hats 

Rag  and  shoddy  industry 

Rattan  industry 

Red  lead 

Refrigeration  plants 

Rendering  plants 

Resin,  distillation  of 

Resin,  solvent  for 

Rifle  barrel,  burnishing 

Rontgen  tubes,  manufacture  of 

Roofers 

Roofing  paper,  manufacture  of 

Roof  tiling  manufacture 

Rubber  industry,  including  rubber  toys 

Rubber  tires,  assembling  of 

Rugs,  manufacture,  dyemg 

Rust  stains,  removal  of 

SaflFron  yellow  dye 

Salamanders,  drying  houses  and  plaster 

Sal  ammoniac 

Salts  of  mercury 

Sanitary  ware  factories 


f  Chlorine,  lead,  sulphur  dioxide,  toxic  color  pig- 

\    ments. 

Carbon  disulphide. 
Arsenic. 
Arsenic. 
Asphalt,  tar. 
Aniline  dyestuffs. 
Mercury  fulminate. 

Dimethyl  sulphate,  methyl  alcohol,  nitrobenzol. 
I  Petroleum,    sulphuric    acid,    hydrochloric     acid 
\  chloride  of  lime,  sulphur  dioxide,  lead,  tar. 
Mercury,  methyl  alcohol,  nitrobenzol,  etc. 
Aniline  dyestuffs,  nitrous  gases,  phenol. 

Phenylhydrazine. 

Phosgene. 
Phosphorus. 

Phosphorus  and  hydrofluoric  acid. 

Benzol,  phosphorus. 

Phosphureted  hydrogen. 

Phosphureted  hydrogen. 

Sulphureted  hydrogen. 

Ammonium  dichromate,  nitrous  fumes. 

Phenol. 

f  Aniline  colors,    bromine  compounds,  cyanogen 
\    compounds,    mercury,   metol,   chromium  com- 
(    pounds,  lead  in  retouching  high  lights. 
Mercury,  arseniureted  hydrogen. 

Bronze,  lead,  methyl  alcohol. 

/  Aniline  dyestuffs,  nitrous  gases,  picric  acid, 
phenol. 

Bronze,  amyl  acetate,  methyl  alcohol  (see  Leaf- 
metal  Workers). 

Arseniureted  hydrogen,  lead,  carbon  monoxide. 

Petroleum,  methyl  alcohol. 

Oxalic  acid. 

Lead. 

f  Hydrofluoric  acid,  hydrochloric  acid,  lead,  man- 
ganese, arsenic,  chrome,  carbon  monoxide  (see 
also  painters.) 

Acrolein,  antimony,  benzine,  lead,  carbon  mon- 
oxide, arsenic,  methyl  alcohol. 

Formaldehyde,  methyl  alcohol. 

Arsenical  color  pigments,  phenol,  tar. 

Picric  acid  (see  also  Explosives). 

Lead. 

Ammonia,  carbon  dioxide,  sulphureted  hydrogen. 

Pyridin. 

Arsenic,  nitrous  gases. 

Antimony,  arsenic,  phosphorus 

Mercury. 

Mercury,  nitrous  gases. 

Acid  fumes,  infectious  diseases, 
f  Aniline  stains,  chlorine,  chromium,  hydrofluoric 
\    acid,  methyl  alcohol,  sulphur  dioxide. 

Lead. 

Ammonia. 

Acrolein,  benzine,  carbon  disulphide. 

Carbon  monoxide. 

Benzine. 

Antimony. 

Mercury. 

Lead,  solder,  tar. 

Tar. 

Lead,  carbon  monoxide  and  other  furnace  gases, 
f  Aniline,     antimony,     arsenic,     benzine,     benzol, 
!  carbon  disulphide,  and  tetrachloride,  lead,  phenol, 
I  sulphur    dioxide,    and    chloride,  tar,      mercuric 
!  sulphide,  methyl  alcohol,  turpentine 

Carbon  disulphide. 

Arsenic  and  other  toxic  dyestuffs. 

Oxalic  acid. 

Aniline  dyestuffs. 

Carbon  monoxide. 

Ammonia. 

Mercury. 

Lead. 


IXDUSTRIAL   POISONS,    ETC. 


747 


List  of  Ixdustrles  and  Poisons — Continued 


Branches  of  industry  in  which  poisoning 
may   occur 


Designation  of  industrial  poison 


Schweinfurth  green 

Sealing  wax,  manufacture  of 

Sewer  cleaning 

Sedimentation  tanks 

Sewing  machine  manufacture 

Sheep  dip  manufacture 

Sheele's  green 

Shellac,  solvent  for 

Shoddy  manufacture 

Shot  manufacture 

Shoe  manufacture 

Silk  bleaching 

Silk  imitation  factories 

Silk  weighting 
Silver  extraction 
Silver  metal 
Silver  plating 
Smelting  furnaces 
Smelting  lead 
Smelting  mercury 
Smelting-sulphur  bearing  ores 

Soap  factories 

Soda  carbonate,  manufacture  of 
Soda  chloride,  manufacture  of 
Soda  sediment,  manufacture  of 
Soda  sulphate,  manufacture  of 
Soda  sulphide,  manufacture  of 
Soda  works 


Soldering 

Staining  wood 
Stannic  acetate 
Starch,  manufacture  of 
Stamping  designs  on  embroidery 
Stamping  mills 
Stearic  acid  factories 
Stearin  refining 
Steel  engra\"ing 
Steel  burnishing 
Stereotyping 
Storage  batieries 
Stone  and  marble  polishers 
Straw  hats,  bleaching 
Straw  deoxidation 
Sugar,  beet  sugar 
Sugar  plants,  saturation  vessels 
Sugar  refineries 
Sulphur,  refining  of 

Sulphur  metals,  manufacture  and  use  of 
Sulphur  extraction  in  gas  purification 
Sulphur  solvent  for 
Sulphur,  water  distillation  of 
Sulphur  and  phosphorus  compounds,  manufac- 
ture of 
Sulphide  colors,  manufacture  and  use  of 
Sulphuric  acid,  manufacture  of 
Sulphurous  acid  and  salts,  manufacture  of 
Surgical  dressings 
Swiss  green 
Tailors 

Tallow  rendering  plants 
Tallow  refining 

Tanneries,  tanning  and  leather  dressing 

Tapestry  printing 

Tar  color  industry 

Tar  works 

Taxidermy 

Telephone  wire,  manufacture  of 

Tempering  and  hardening,  steel  magnets,  piano 

wire,  springs,  files,  etc. 
Textile  fabrics,  deoxidation  of 
Textile  industry 
Textile  printing 
Thermometers 


Arsenic. 

Turpentine. 

Ammonia,  carbon  dioxide,  sulphureted  hydrogen. 

Carbon  dioxide,  sulphureted  hydrogen. 

Amyl  acetate. 

Arsenic. 

Arsenic. 

Methyl  alcohol. 

Hydrochloric  acid,  sulphuric  acid. 

Antimony,  arsenic,  lead. 

Benzine,  methyl  alcohol. 

Sulphur  dioxide. 

j  Carbon  disulphide,  ammonium  sulphide,  nitrous 

1    fumes. 
Lead. 

Mercury,  cyanogen  compounds. 
Arsenic,  lead,  antimony. 
Cyanogen  compounds,  mercury. 
Carbon  monoxide  and  other  furnace  gases. 
Lead. 
Mercury. 
Sulphur  dioxide. 

/  Acrolein,  nitrobenzol,  sulphuric  acid,  pyridin,  am- 

\    monia  cyanide,  sulphur,  tar. 
Ammonia. 

Hydrochloric  acid,  chlorine. 
Nitrous  gases. 

Arseniureted  hydrogen,  hydrochloric  acid. 
Sulphureted  hydrogen. 

Sulphureted  hydrogen,  hydrochloric  and  sulphuric 
acids. 

f  Arseniureted    hydrogen,    carbon  monoxide,  hy 

\     drochloric  acid,  lead,  nitrous  fumes. 
Aniline,  chromium,  methyl  alcohol,  phenol. 
Hydrochloric  acid. 
(See  Putrefaction  Gases.) 
Lead  f  nd  rosin. 
Mercury,  nitrous  gases. 
Acrolein. 

Carbon  disulphide. 
Mercury. 

Antimony,  sulphuric  acid. 
Antimony,  lead,  carbon  monoxide. 
See  Batteries. 
Lead. 

Sulphur  dioxide. 
Nitrous  gases. 
Ammonia. 
Carbon  dioxide. 

Phosphorus,  sulphureted  hydrogen. 
Benzol. 

Sulphureted  hydrogen. 
Carbon  disulphide 
Carbon  disulphide,  sulphur  chloride. 
Sulphureted  hydrogen. 

Sulphureted  hydrogen. 

Sulphureted  hydrogen. 

Nitrous  gases,  sulphur  dioxide. 

Nitrous  gases,  sulphur  dioxide. 

Mercury,  phenol. 

Arsenic. 

See  Garment  Workers. 

Acrolein,  sulphuric  acid. 

Carbon  disulphide,  chlorine,  acid  fumes. 

Ammonia,  anthrax,  arsenic,  carbon  dioxide  (in 
tan  pits),  chromium  compounds,  lead    (white 

leather),  sulphur  dioxide,  sulphureted  hydrogen, 
i   acids,  benzine,  amyl  acetate. 
Turpentine,  toxic  color  pigments. 
Aniline,  chromium  compounds,  phosphorus,  etc. 
Tar. 
Arsenic,  carbon  disulphide. 

Lead. 
Acrolein,  cyanogen  compounds,  lead. 

Nitrous  gases. 

Arsenical  colors,  lead,  sulphuric  acid. 

Antimony,  arsenic,  chromium,  lead  compounds. 

Mercury. 


748        ETIOLOGY   AND   PROPHYLAXIS    OF   OCCUPATIONAL  DISEASES 
List  of  Industries  and  Poisons — Concluded 


Branches  of  industry  in  which  poisoning 
may  occur 


Thorium,  preparation  of 
Tin  foil 

Tin  ware  and  tin  shops  and  tinning 

Tissue  hardening  and  preserving 

Toluol,  manufacture  of 

Toys,  coloring  of 

Toy  balloons,  filling 

Transfer  chromos 

Turkey  red,  mordant  for 

Typefounders 

Typesetters 

Ultramarine  works 

Upholstery 

Valeric  acid,  manufacture  of 

Varnish,  manufacture  and  use  of 

Vinegar,  manufacture  of 
Vienna  green  and  red 
Viscosine,  manufacture  of 

Vulcanizing  and  red  dyeing  of  rubber 

Wall-paper,  manufacture  of 
Wall-paper,  hangers  and  scrapers 
Waste  waters  of  industrial  plants  making  use  of 
organic  matter 

Watch  factories 

Water  gas,  carburizing 
Water  gilding 
Waterproof  material 
Wax  bleaching 
Wax  refining 
Weather  vane  gilding 
Well  gas 
Whip,  factories 
White  lead 
White  metal 
Window  shades,  green 
Wine  cellars 
Wine  preserving 

Wire  galvanizing  with  zinc 

Wire  tempering 

Wool  bleaching 

Woolen  refuse,  deoxidation  of 

Wood  alcohol 

Wood  deoxidation  of 

Wood  impregnating  and  preserving 

Wood  staining  and  polishing 

Workrooms,  crowded 

Xyloidine,  manufacture  of 

Xylol 

Yeast,  compressed,  factories 

Zapone  lacquer 

Zinc  chloride,  manufacture  of 

Zinc  deoxidation  of 

Zinc  ore  smelting 

Zinc  plating 

Zinc  sulphate,  martufacture  of 
Zoological  preparations 


Nitrous  gases. 
Lead. 

(■  Afnmonia,  arseniureted  hydrogen,  chlori'ne,  car 

\    bon    monoxide,    hydrochloric    acid,    lead,    sul- 

\    phuric  acid. 
Formaldehyde. 
Benzol. 
Arsenic. 

Arseniureted  hydrogen. 
Lead. 

Chromium  compounds. 
Acrolein,  antimony,  arsenic,  lead. 
Benzine,  lead. 

Sulphur  dioxide,  sulphureted  hydrogen. 
Anthrax  and  infectious  diseases. 
Amyl  alcohol. 

/  Acrolein,  ammonia,  benzine,  lead,  methyl  alco- 

\    hoi,  turpentine. 
Acetaldehyde. 
Arsenic. 
Nitrous  gases. 

/  Antimony,   arsenic,   carbon  disulphide    (see  also 

1    Rubber). 

Arsenic,  lead  (see  also  paper  mills). 
Arseniureted  hydrogen. 
Sulphureted  hydrogen. 

f  Benzine,   cyanogen  compounds,   lead   for  dials, 
\    nitrous  gases  (see  also  Brass  and  Tempering). 
Benzol. 
Mercury. 
See  Rubber. 

Chromium  compounds,  sulphur  dioxide. 
Carbon  disulphide. 
Mercury.  _ 
Carbon  dioxide. 
See  Rattan  Industry. 
Lead. 
Antirnony. 
Arsenic. 
Carbon  dioxide. 
Sulphur  dioxide. 

f  Aminonia   arseniureted  hydrogen,    hydrochloric 

\    acid,  sulphuric  acid,  zinc. 
Lead,  acerolein,  cyanogen  compounds. 
Sulphur  dioxide. 
Nitrous  gases. 
Methyl  alcohol. 
Nitrous  gases. 
Arsenical  paints,  phenol,  tar. 

f  Aniline  colors,  chromium  compounds,  lead,  ar- 

■j    senic  colors,  methyl  alcohol,  alcohol  denatured 

I    with  pyridin,  phenol,  petroleum. 
Carbon  dioxide. 
Nitrous  gases. 
Benzol. 

Carbon  dioxide. 
Amyl  acetate. 
Arseniureted  hydrogen. 
Nitrous  gases. 

/  Antimony,  arsenic,  carbon  monoxide,  lead,  man- 

\    ganese,  sulphur  dioxide. 

I  Ammonia,  arseniureted  hydrogen,  hydrochloric, 

\    sulphuric  acids  and  zinc. 
Arseniureted  hydrogen. 
Formaldehyde. 


OCCUPATIONAL  MORTALITY  AND,  MORBIDITY    STATISTICS,  ETC.       749 
Mortality  axd  Morbidity  Statistics* 


Occupation  and  age  at 
death 


Deaths  of  persons  at  least  10  years  of  age  engaged  in 
certain  specified  occupations 


All 
causes 


Per  cent,  of  all  causes  at  specified 


•3  m 

o  Sf 

^  s 


U         P.  cS 

CIS      a* 


go 


All  occupations  reported. 


10  to  14  years. . . . 
IS  to  19  years. .  .  . 
20  to  24  years.  . . . 
25  to  34  years. .  . . 
35  to  44  years.  . . . 
45  to  54  years. . . . 
55  to  64  years. . . . 
6s  to  74  years. . . . 
75  to  84  years. . . . 
8s  years  and  over. 
Unknown 


210,507     2.2 


All  occupations  reported, 
females 


10  to  14  years. . . . 
IS  to  19  years. .  . . 
20  to  24  years. . . . 
25  to  34  years. . . . 

35  to  44  years 

45  to  54  years. . . . 
55  to  64  years. . . . 
65  to  74  years. . . . 
75  to  84  years. . . . 
85  years  and  over. 
Unknown 


1-6 

S.356| 

12,1971 

28,635! 

32,461 

35.7ii| 

35,953 

33,462 

20,802 

5.464 

290 


27.459 


4.0 
9.0 
7.6 
5.0 
2.7 
1.5 
0.7 
0.3 
.0.1 


i4-8[   SS 

4.0| 

23.0    0.5 


31.7 

31.0 

23.6 

14.4 

7.5 

3.6 

1.3 

0.6 

8.3 


7.3 

I.I 
0.5 
0.6 
1.2 
2.7 
5.9 


0.9 
1.3 
3.3 

6.8 
9.4  10 
8.4  13.4 
S.6 
3.1 
2.8 


71  12.7 
2,198  9.2 
3.6S3 


S.141 
4.SOO 
4.398 
4.174 
1,887 
1,078 
338 


Agricultural    pursuits, 
males: 

25  to  34  years 

35  to  44  years 

45  to  54  years 

55  to  64  years 


Agricultural  laborers. 

25  to  34  years 

35  to  44  years 

45  to  54  years 

SS  to  64  years 


21I   4.8 


3.711!  7-9 

4.i38i  45 

5, 816  2.4 

8.424!  I.I 


1,800  7.1 

i,70ij  2.8 

1.958  1.8 

2,269  0.7 


26.8 

33.3    0.7 

39.8    0.7 

35.7    3-1 

21.310.1 

10.2  15.6 

5.6  14-7 

3. 21   9-5 

l.8i   7.0 

4.1 

4.8 


4.8 


II. 9 

2.3 
3.8 
3.S 
4.8 
7.7 
11-3 

15. 4 
18.9 

18. 5 
14. 1 

7.2 


10.3 

S.6 
4-7 
4-8 
6.4 


•4 

■4 

.6 

•  3 
10, 

.4  12 
3jlS 
7il7 

,i|i6 
S 
9 


26 

19-3  45 
12.3!  8.4 
6.7  10. I 


I.6I  1.4 
2.6 
5-9 


28.6 


14.9 
8.4 


I.O 
2.9 
S.I 
7.6 


8.0 

8.5 
7.0 
6.3 

7.4 
95 
9.0 
8.3 
7.6 
7.0 
6.3 
45 


7.0 

7.0 
6.0 
S.3 
S.7 
6.4 
8.0 
9.0 
9-1 
9.0 
S-O 


II 


4.6     6.3 
7.4|   8.4 
1.9    8.4 
5  16.8    7.6 


1.6 
2.S 
S.3 

II. S 


8.S 

I.I 
1.5 

2.l| 

4.0] 

6.61 

9.7 
II. 7 
12.0 
10. S 

7.7 


2.6 


No.  of 
days  of 
sickness 

per 
annum 
per  100 
mem- 
bers' 


No.  of 
deaths 
per  100 
mem- 
bers' 


10. 


1.7  42.0 
2.2J26.6 
3.4  21.6 
3.7|i8.4 
3.7|i4-4 
3.s|i0.2 
2.3;  6.3 
1. 21  3.9 
O.S  3.1 
0.31  3-4 
2.8    6.6  41.0 


7.3 

2.8 

2.6 

3.0 

4.6 

7.7 

10. o 

II, s 

II.  I 

9.2 

7.1 


2.7 

4-7 
6.9 
9.0 


1.6 

1-4 
3.0 
2.9 
2.4; 

l.lj 
0.9I 
0.8 
0.3! 
0.4I 

4-8| 


S.6 
S.3 
3.9 
3.0 
2.6 
2.9 
2.5 
2.9 
4.4 
4-1 
4.8 


4.8|   6.S 

8.5|lO.O 

13. 8  10.6 

16. 9!   8.8 


2.1 
4-4 
S.7 
9.6 


4-2  18.3 
5-4, 15-4 
3.9  9.1 
2.3    6.1 


5.2  20 
s.6  18.0 


3.2 
2.4 


9.6 
7.4 


1020  I 159 


1.34 


*  The  mortality  statistics  showing  the  number  and  per  cent,  distribution,  by  important  causes, 
of  deaths  of  persons  at  least  10  years  of  age  engaged  in  certain  specified  occupations,  classified  by 
age,  for  the  registration  area  in  the  United  States,  are  based  upon  data  published  in  Bulletin  108. 
Bureau  of  the  Census,  in  1909. 

'  The  morbidity  statistics  are  based  upon  a  study  of  sickness  and  mortality  hazards  in  certain 
occupations,  compiled  from  the  experience  of  the  Local  Sick  Benefit  Society  of  Leipsic,  1887  and 
1904,  by  Dr.  Lee  K.  Frankel,  Vice-President  Metropolitan  Life  Insurance  Company,  New  York, 
and  presented  before  the  Detroit  Conference,  Niagara  Falls,  September  4,  19 13. 


750        ETIOLOGY   AND   PROPHYL.\XIS    OF    OCCUPATIONAL   DISEASES 


Mortality  and  Morbidity  Statistics. — Continued 


Occupation  and  age  at 
death 


Deaths  of  persons  at  least  lO  years  of  age  engaged  in 
certain  specified  occupations 


All 
causes 


Per  cent,  of  all  causes  at  specified  age 


f-  ;h 


'E'rt 


BO 


,'f, 

•a 

ID 

isi 

."2 

pq<u 

1 

No.  of 

days  of 

sickness 

per 

annum 
per  100 
mem- 
bers! 


No.  of 
deaths 
per  loo 
mem- 
bers* 


G     1     "rt 


Farmers,  planters,  and 
overseers: 

25  to  34  years 

3S  to  44  years 

45  to  54  years 

55  to  64  years 


Gardeners,  florists,    nurs- 
erymen, etc.: 

25  to  34  years 

35  to  44  years 

45'to  54  years 

55  to  64  years 


Agents — -Transportation : 

25  to  34  years 

35  to  44  years 

45  to  54  years 

55  to  64  years 


Aluminum  and  brass  fac 
tory  workers 

Artificial  ice  makers 

Asphalters 

Asphalt  and  concrete 
workers 


Bakers 

25  to  34  years. 
35  to  44  years. 
45  to  54  years. 
55  to  64  years. 


Bankers  and  brokers. 

25  to  34  years 

35  to  44  years 

45  to  54  years 

55  to  64  years 


Barbers  and  hairdressers. 

25  to  34  years 

35  to  44  years 

45  to  54  years 

55  to  64  years 


1628 
2091 
3366 
55891 


9 

6.0 
2-9 
1.2 


69  5.8 

96  4.2 

184  I.I 

223'  0.4 


262 
366 
552 
650 


5-7 
4.4 
1.6 
0.8 


24.9 
18.8 
II. o 

6 


23.2 

33-3 

15.2 

7.2 


32.8 
18.9 


2.3 

5. 5 

10.4 

II. o 


1.4 

7-3 

6.5 

13.0 


2.3 

5.2 

9.6 

10.2 


1.4 
2..  8 
6.2 
I-S 


952 
141 
176 
198 
181 

712 
74 
119 
174 
165 


283 

345 
314 
180 


0.6 


2.8 
6.8 
2.S 


3-9 
2.6 
1.3 
0.6 


29. 1 

29.0 

18.7 

9-4 


36.1 

12.2 

3.4 

4.6 


1-4 
4.0 
9.6 
6.6 


1.4 
3-1 
5-5 
7.6 


0.4 

1.4 

6.9 

12.0 


4.6 
6.6 

II. 5 
17. 1 


4-3 


14.7 
16 


S.3 

7.7 
II. 4 
15.7 


0.7 
1-7 
4-5 
8.8 


4-1 
0.9 
7.5 


9.8 


40.6 
25.8 
16.2 

II. 7 


I.I 
2.6 
4.8 
6.7 


0.4 
2.6 
7.3 
8.9 


1.4 
10.2 
9.6 

17.7 


2.8 

2.7 

10. 1 

14.9 


7-1 
8.4 

12. 4J 
19.4 


6.4 

7.4 

7. 

7. 


8.7 

9.4 

II. 4 

9-9 


7.6 
7.4 
7.4 
6.6 


3.3 
5 

7.4 
8.8 


4-3 

S.2 

9.2 

10.3 


3.8 

7-1 

12.0 

10.9 


12. 1 
7.4 
8.6 
8.3 


II. I 

14.9 

8.4 

9.8 


4.2 
6.1 
6.4 
3-3 


2.8 

8.S 

10.6 

10. 5 


8.3 

5-4 
17.6 
14.4 


3 
5 
4 
2.3 


4-3 
5.2 
3.8 
2.7 


6.1 
7-4 
5-3 
4-5 


13.4 

II. 7 

8.2 

5-4 


13.0 
7.3 
5.4 
5.8 


10.7 
7.6 
6.9 
3-7 


5.7 

4.5 
4-5 
5 


5.6 
8.1 
4.2 
3.4 


2.5[  4-6 

9.6|  4.6 

9.6  3.2 

12. 8i  1.7 


12.8 
5-7 
5.6 
3-3 


5.6 
5.4 
2.5 
3-4 


7.1 
6.9 
7.0 
3-3 


761 

701 

1317 

1320 


0.50 
0.56 
0.88 

0.71 

O.IS 


OCCUPATIONAL  MORTALITY  AXD  MORBIDITY  STATISTICS 


751 


Mortality  axd  Morbidity  Statistics. — Continued 


Occupation  and  age  at 
death 


Deaths  of  persons  at  least  10  years  of  age  engaged  in 
certain  specified  occupations 


All 


Per  cent,  of  all  causes  at  specified  age 


U     I    0<  n) 
cot; 

rt   1  as 


Bartenders 

25  to  34  years. 
35  to  44  years. 
45  to  53  years. 
55  to  64  years. 


I 1 

359    3-337. 0'  0.6 
442    0.929.4    2.0 

203' 17.7    4.9 

52 1.9    5.8 


2  5 


,9'   6.1     9.7    6.1 

1.4  8.8J  971  9.5 
3.9  8.4  14.8,12.3 
9.6  21.21   9.6  13. S 


3-3l  4.4 
2-7;  4-7 
3.0  6.4 
1.9 


Basket  makers. 


Blacksmiths 

25  to  34  years. 
35  to  44  years. 
45  to  54  years. 
55  to  64  years. 


216 
280 

409 
48s 


Bleachers,  dyers,  laundry 

workers 

Boat    builders    and     car- 
penters  

Boatmen  and  sailors 

25  to  34  years 

35  to  44  years 

45  to  54  years 

55  to  64  years 

Bookkeepers  and  account- 
ants  

25  to  34  years 

35  to  44  years 

45  to  54  years 

55  to  64  years 


4.2  29.6]   1.9]   1-4    6.5    7.4 
3.927.1    3.2    2.5'  6.410.0 
,7,15.9    9.0    7.110.8 
,4    6.0  l0.5;iO.S  iS-3    8.7 


242]  6.6 ;l6.s 
242J  3-7, 15-7 
309  0.6  12.0 
288    0.3    5-9 


1.7 
2.5 
6.5 

9-4 


0.8    4 

4Si   9 

4.910.7 

9.712.2 


6.2 
8.3 
9.4 
9-4 


S.6 
SO 

8.8 
10.7 


4.5 

4-S 

9.4 

II. 8 


347I    S-S  42.9'    1.2     I 


294 
280 
305 


Bookbinders. 


Boot  and  shoe  makers  and 

repairers 

25  to  34  years 

35  to  44  years 

45  to  54  years 


256 
260 


3-4  31.6 
1.4  12.9 
0.3    5.2 


.4    I 
•2,   6 

.5:11 


,4]  S. 
,4  II, 
4  13, 
,1117. 


4.7;3S.S| 
I.5l3i-9i 


339    0.6  16.8 


55  to  64  years. 


456 


Brass  and  aluminum 

workers 

Brewers  and  malsters .... 

Brick     and     terra     cotta 
workers 

Bronze  factory  workers.  .  . 

Brush  and  hair  workers.  . 


0.7 


6.6 


4.4 


1.2    7-0 

3.1    9-2 

7.1  10. O 

I2.sii4-7 


S.3|  2.9 
7-S|  6.S 
9-3  10.7 


3.7 
2.S 
3.2 
2.3 


8.3 


No.  of 
days  of 
sickness 

per 
annum 
per  100 
mem- 
bers' 


N'o.  of 
deaths 
per  100 
mem- 
bers' 


a  !  -3 


633  771 


947 
1002 


0.67 


I.  ID 
O.S4 


979  9660.790.58 


3.3 
4-1 
I.O 

1.7 


6.2 


13.4 


7.4  4-3 

9-6|  5-4 

13.0J14.7 

5-7  13. 1 


31.8 


877 
1278 


3-9 

5-4 
5.3 
2.6 


8.2 
6.5 
3.2 
SO 


642 


761 
1 106 

III8 
890 
910 


S6o 


1238 


0.750.34 


0.690.63 


932  0.68  0.41 


0.50 
1. 16 

0.89 
0.33 
0.9S 


752        ETIOLOGY   AND    PROPHYLAXIS    OF   OCCUPATIONAL   DISEASES 


Mortality  and  Morbidity  Statistics. — Continued 


Occupation  and  age  at 
death 


Deaths  of  persons  at  least  lO  years  of  age  engaged  in 
certain  specified  occupations 


Per  cent,  of  all  causes  at  specified  age 


All 


>..2 


11 

a  as 


No.  of 
days  of 
sickness 

per 
annum 
per  lOO 
mem- 
bers' 


No.  of 
deaths 
per    lOO 
mem- 
bers' 


Butchers 

25  to  34  years. 
35  to  44  years. 
45  to  54  years. 
55  to  64  years. 


Cabinet  makers,  wood 
polishers 

Cabmen  and  drivers 

Card-board  and  paper-box 
workers 

Carpenters'  helpers 


208 
293 
341 
29s 


Carpenters  and  joiners. 

25  to  34  years 

35  to  44  years 

45  to  54  years 

55  to  64  years 


Cement    mixers    and   hod 

carriers 

Chemical  industry  workers 
Cigar  and  tobacco  workers 
Clerks  and  salesmen  and 


565 

874 

1256 

1621 


Clerks  and  copyists: 

25  to  34  years 

35  to  44  years 

45  to  54  years 

55  to  64  years. . . . 


Clergymen: 
25  to  34  years. 
35  to  44  years. 
45  to  54  years. 
55  to  64  years. 


Compositors  and  type- 
setters  

Concrete  and  asphalt 
workers 

Confectioners 

Cooks 


1762 
1297 
1056 
848!  o 


3.4 
4-1 


0.3 


39.4 
22.9 
13.8 


1.4 
4.8 
6.7 


6.8  12.5 


7.1 
3.3 


4-8 


61 
104 
176 
25s 


3.3 
S.8 
4-5 
1.2 


1.9 

2.7 

4.1 

II. 5 


5.3 

9.6 

13.2 

12.2 


26.0 

22.5 

13.6 

8.5 


44.2 

31. S 

17.0 

7 


41.0 

19.2 

9.1 

2.7 


2.3 

4.8 

7.1 

10. o 


0.9 

3-3 

6.5 

10. o 


4.8 
7.7 

10.4 
16.3 


1.6 

3.4 

6. 

8. 


1.6 
S.8 
7.4 
9.4 


1.5 

2.7 

7.6 

10. o 


7.7 
8.5 

10.6 


5.3 

7.5 
10.4 
IS. 4 


3.3 
9.6 

12. S 
14-5 


10. 1 
8.S 
S.6 
7.5 


S.8 

8.2 

10.3 

13.2 


5.8 
8.7 
8.9 
7-7 


5.1 
5.9 
8.9 
9.3 


6.4 

10.7 

8.0 

7.S 


6.6 

7.7 
7.4 
7-1 


II. 3 
15.6 


6.6 

7-7 

13.6 

17.3 


577 


2.9 

4.4 
S.3 
5.4 


8.7 
8.2 
6.5 
3.4 


810 
899 


1574 
1358 


877 


1165 


4.1 
3.8 
3.8 
3-2 


24.4 
15.8 


1439 
947  1342 
909  1 158 


404 


4-1 
3-2 
3.6 

1.7 


1.6 
I.O 


0.4 


53 
4-5 
4-9 
3.4 


3.3 
3.8 
5.1 
4.3 


1320 
524 


733 


893 


0.36 


0.72 
1.09 


1.06 
0.80 


0.68 


0.49 


0.90 

0.850.85 

1.440.9s 


0.48 


0.83 


0.71 
0.08 


0.34 


0.34 


OCCUPATIONAL    MORTALITY    AXD    MORBIDITY    STATISTICS 


753 


^lORTALiTY  AXD  MORBIDITY  STATISTICS. — Continued 


Occupation  and  age  at 
death 


Deaths  of  persons  at  least  lo  years  of  age  engaged  in 
certain  specified  occupations 


All 


Per  cent,  of  all  causes  at  specified  age 


f->° 


°  ti 


g     .2  «    -2 

!S        3—     "Si' 


No.  of 
days  of 
sickness 

per 

annum 

per  loo 

mem- 

berB> 


•3     e 


No.  of 
deaths 
per  loo 
mem- 
bers' 


•3       S 


Coopers. 


25  to  34  years. 
35  to  44  years. 
45  to  54  years. 
55  to  64  years. 


30 
59 

84 
89 


•  '33-3 1   3.3  16.7  13-3'  3-3    6.6 

.  45-8     1.7....'   6.810.2    5.1  5-1  10 

.23.8    7.1     3.6  15.8  10.7     7.1  3.6    8.3 

I  10. I  14.6    6.7  16.9    9.0    7.9  2.2    3.4 


Decorators   and   painters: 


Domestic    and    personal 

service:  males 

25  to  34  years 

35  to  44  years 

45  to  54  years 

55  to  64  years 


IO17 


7303 
8370 
8398 
6914 


45  32.3 
2.3  25.5 
I.I  17. I 

0.6  I0.2 


I  .2 
2.6 


8.2     7 


5.1  9.5  4-6 
8.3  II. I  7.2 
3  12.2  10.7  10. 1 
9  147  10.9  13.4 


3.5  12.6 

2.6  10.8 

3.0  8.5 

2.1  5.6 


Domestic    and    personal 

service:  females 

25  to  34  years 

35  to  44  years 

45  to  54  years 

55  to  64  years 


0.48 


3155  3.233. 2     3.0     1.5     6.0  6.5     4-7 

3066  2.221.3    9.2    3.910.4  6.6    7.8 

3232  I.I  10. 1  14. 1     8. 913. 1  8.210.7 

3280  0.6    5. o  13.9  12.8  15.2  8.512.2 


2. 1 
1. 1 


3.0 
2. 1 

2.7 
2.5 


Janitors  and  sextons: 

25  to  34  years 

35  to  44  years 

45  to  54  years 

55  to  64  years 


78 47.4  2.6 10.3  10.3  1.3  3.8 

157     1. 921. 7  2.5    3.2    8.313.4    8.3  5.7  9.6 

219    0.914.6  9.1    6.8  13.7  II. 9  10. o  5.0  55 

276....     9.4  9.1     8.016.712.3130  2.9  5-4 


Draymen,  hackmen,  team- 
sters, etc 

25  to  34  years 

35  to  44  years 

45  to  54  years 

55  to  64  years 


Dressmakers.  . .  . 
25  to  34  years. 
35  to  44  years. 
45  to  54  years. 
55  to  64  years. 


1333 

3.9 

35.8 

1369 

1-3 

29.3 

1086 

1-4 

18.2 

736 

0.5 

10.2 

899 


I.O      1.2      5.910.0      4.2  2.914.2 

2.6      2.5      8.410.8      6.3  2. 215.  I 

5.6    4.2  II. o    9.7     9  9  2.7  13.4 

9.910.514.1      8.712.2  1.512.0 


186    3.240.3'    1.6    I.I    S.9  5-4'    5-4 

191     1.6  19.9  14. 1     2.6    9.9  5.2    9.4 

19s  .  .  .  .  II  .8  24.6    6.7118  8.2    5.6 

143....     8.4  22.4  II  .9  18.2  9.810.5 


2.7 
3-1 


3.8 


Dyers,    bleachers,    and 
laundry  workers 


979I   9660.7910.58 


48 


754 


ETIOLOGY   AND   PR0PHYL.4XIS    OF    OCCUPATIONAL   DISEASES 


JMoRTALiTY  AND  [MORBIDITY  STATISTICS. — Continued 


Occupation  and  age  at 
death 


Deaths  of  persons  at  least  lO  years  of  age  engaged  in 
certain  specified  occupations 


Per  cent,  of  all  causes  at  specified  age 


AU 
causes 


.2 

o 

It 

(u  a 

J2  — 

c 

01 

f-^ 

O 

'ft'ca 


w 


Xoof 
days  of 
sickness 

per 
annum 
per  lOO 
mem- 
bers' 


No  of 
deaths 
per  lOO 
mem- 
bers' 


Electric  apparatus  factory 

workers 

Engineers  and  firemen 
(not  locomotive) 

25  to  34  years 

35  to  44  years 

45  to  54  years 

55  to  64  years 


girls, 


Errand    boys    and 

porters,  etc 

Excavation  laborers  and 
house  wreckers 

File  makers 

Flour  mill  workers 

Forgemen  and  blacksmiths 

Furriers  and  fur  dyers.  .  . 

Gas  workers 

Glaziers 

Hair  and  brush  workers.  . 

Hatters 

Hide  industry  workers .  .  . 

Hod  carriers 

Hotel  kitchen  helpers.  .  .  . 

House  wreckers 

Illuminators  photoen- 
gravers  and  photog- 
raphers   

Instruments  of  precision 
makers 

Iron  founders  and  machin- 
ists  

Jewelry  industry,  gold  and 
silver 

Iron  and  steel  workers... 

25  to  34  years 

35  to  44  years 

45  to  54  years 

55  to  64  years 

Laborers  (not  specified) .  . 

25  to  34  years 

35  to  44  years 

45  to  S4  years 

55  to  64  years 


471 
605 
694 
683 


8.3 
3.6 
0.9 
i.o 


25.7 

18.7 

10. 5 

7.0 


1.5 
5.6 
7-9 


0.2 
2.3 
6.1 


10.8  1 1. 9 


6.6 

8.3 

12.2 

14.8 


6 

9.6 

9.4 

7 


524 

SO 

25.2 

2.3 

617 

3.6 

22.0 

2.3 

556 

1-3 

15.3 

4.0 

394 

1.0 

7.9  10.2 

5.180 

S.I  30.8     1.0 

5.606 

2.5  25.9!   2.4 

5.635     I.I  18.2    S-S 

4.797 

0.7 

10.7 

8.2 

I.I 

2.8 

6.8 
8.6 


3.6 

7.9 

10.3 


14.7  II. 2 


10.9 
12.2 
II. 3 


5.0  10.2 
8.o'l3.l 
4.8  12.5  II. 9 
7.4  14. 1  12.2 


3-4 
S-S 
7.9 
8.4 


4-5 
6.4 
91 

13. 5 


722 
767 


3.6 
31 
4-5 
1.6 


18.9 

17.5 

9-9 

6.9 


621  1043  0.77  0.57 


IS19 
1117 

651 
1002 

736 
1084 

804 

910 
1124 
1123 
1439 

689 
1519 


3.6 


2.9 
1.5 


28.1 

20.9 

14.0 

7.1 


2.9  13.9 

1.7  12.6 
2.5  9-3 

i.s'  5.7 


573 

955 

I189 

461 
1256 


. .  .  .11. 
.  .  .  .  I 

[o 

. . . .  'o 
II930 
. . . .  o 
o. 

o. 

I 

...  II, 

1978  I 
. . . .  o 
1810  o 
. . . .  I 


814  o. 
II470. 
1666  o. 
o. 


0.61 


0.7S 


0.40 


770.41 
780.SI 


71 


2.30 


OCCUPATIONAL    MORTALITY    AND    MORBIDITY    STATISTICS  755 

Mortality  and  Morbidity  Statistics. — Continued 


Occupation  and  age  at 
death 


Deaths  of  persons  at  least  10  years  of  age  engaged  in 
certain  specified  occupations 


All 
causes 


Per  cent,  of  all  causes  at  specified  age 


No.  of 
days  of 
sickness 

per 
annum 
per  100 
mem- 
bers' 


No.  of 
deaths 
per  100 
mem- 
bersi 


'o.'a  1 
o  !3  1 


o  E  j  «    1 

a>S3  I  .SP« 


Lace  factory  workers 

Ladies'   tailors   and   mill- 


Laundresses 

25  to  34  years. 
35  to  44  years. 
45  to  54  years. 
55  to  64  years. 

Lawyers: 

25  to  34  years. 
35  to  44  years. 
45  to  54  years. 
55  to  64  years. 


Leather,  artificial  and  oil- 
cloth workers 

Locksmiths 

Lithographers 


Machinists 

25  to  34  years. 
35  to  44  years. 
45  to  54  years. 
55  to  64  years. 


Manufacturers    and    offi- 
cials, etc: 

25  to  34  years 

35  to  44  years 

45  to  54  years 

55  to  64  years 


212 
216 
243 
i6s 


105 
141 
236 
303 


3.3 
3.2 
1.6 


330 

18.5 
II. 5 

2.4 


25-7 

19.9 

8.9 

SO 


Manufacturing    and    me 

chanical  pursuits, 

males: 

25  to  34  years 

35  to  44  years 10,405 

45  to  54  years 11, 597 

55  to  64  years 11,408 


574 
567 
567 
556 


164 
327 
526 
708 


Manufacturing    and    me- 
chanical  pursuits, 
females: 
25  to  34  years 


5-435. o 
3-5J23-8 
0.7113 
i.i!    7 


S-S 
4-3 

2.7 
1. 1 


3-81    x.4i   7.5 

7.9     3.2|I2.0 

8.6    8.2[is.2 
10.3  12.7  13-9 


1.9 
2.1 
6.8 
8.6 


1.9 
4-3 
13. 1 
12. s 


4.21   3.8 

8.8J   9.3 

II. 5    9.1 

10.3  13.9 


7.6 

7.1 

9.7 

16.5 


1-9 

17.7 

8.9 

6.6 


14.9 
9.3 
12.5 


S 

!i; 

•a 

-s 

B 

S 

^ 

1.9 
1.9 
0.4 


7.6 
4.3 
4.2 
1.7 


28.0 

14. 1 

7.2 

3-2 


4.7i30.8 
2.S>50 
l.4|lS.6 
0.6    8 


1 .2 
3.7 


I.! 
6.4 
7.4 
5.6 


i.7[   4-5 

l.9i    7.8 

4.2|i3.9 

12.8  16.2 


3.0    3.0 

4.3{   8.3 

7-4    9.S 

II. 2  15.7 


1.5  l.i^   4.8 

3.6  2.6]   7 
6.6J  5.7110.7 
9.3I10.1115.O 


10 


6.7 
8.3 
6.3 
6.6 


7.0 
9-1 
9.0 
8.0 


4.0 

4-4 

1.3 

12.9 


3.0 
8.3 

12.2 
II. 7 


3.8 
6.5 
9.6 

II. 5 


.4  40. 8     2.9     1.2     7.6 


5.1 
4-4 
4.4 
2.3 


3.0 
1.8 

5.7 
1. 1 


4 

3.6 
3.8 
2.6 


4-7 
2.8 
1.6 
30 


9-5 
3.S 
S.S 
2.6 


ISS 

II. 6 

8.6 

5.6 


18.3 

14.4 

9-9 

5.9 


21.9 
16 
II. o 

6.3 


620 
691 


878 
892 
650 


847 10.83 


966  ....  0.58 


0.54 


1.38 

O.S9 
0.53 


1189  1666  0.71 


S.I     so'   3.3     2.8 


756        ETIOLOGY   AXD   PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 


Mortality  and  Morbidity  Statistics. — Continued 


Deaths  of  persons  at  least  10  years  of  age  engaged  in 
certain  specified  occupations 


Occupation  and  age  at 
death 


Per  cent,  of  all  causes  at  specified  age 

i-i 

1 

•n 

> 

52 

a 

-^ 

A 

All 
causes 

:2 
0 

erculos 
ungs 

cer 

>..2 

'ft'tS 

II 

Art 

:2 

13 

0, 

US—        c 

>. 

s-s      ca 

^a 

«j    1  a^    t.  <a      -ri 

0 

H 

E-.0      0 

W 

Oc 

m 

< 

Xo.  of 
days  of 
sickness 

per 
annum 
per  100 
mem- 
bers 1 


No.  of 
deaths 
per  100 
mem- 
bers' 


35  to  44  years. 
45  to  54  years. 
SS  to  64  years. 


Marble  and  stone  cutters. 

25  to  34  years 

35  to  44  years 

45  to  54  years. 

S5  to  64  years 


730 
600 
462 

822 
75 
IS6 
177 
218 


Masons  (brick  and  stone) 

25  to  34  years 

35  to  44  years 

45  to  54  years 

55  to  64  years 


Merchants    and    dealers 
(except  wholesale) : 

25  to  34  years 

35  to  44  years 

45  to  54  years 

55  to  64  years 


Metal    polishers    and 

grinders 

Milliners. 


Miners  and  quarrymen. 

25  to  34  years 

35  to  44  years 

45  to  54  years 

55  to  64  years 


346 
419 

512 


837 
1.369 
1,901 
2,091 


1. 126. 311. 4  3.212.3  5.51  7.8  1.6  2. 
0.312.320.3  7012.3  7.7  8.0  0.7  3- 
0.4    9.3  18.8  II. 3  16.5  10.4    8.7    0.4     3. 


2.7J46. 
2.6  41 . 
O.6I42. 
0.5  19- 


71... 
o  3. 
9  5- 
3     7- 


1-3 
1.9 
4.0 


6. 7112. 2 
3-21  6.8 
8.5    6.9 


6.9  13-8    6.7 


4-833. 
0.6  29. 
1.4  19. 
0.2     7. 


8     3. 

6    6. 
4  II. 


3-7  10. 1 
9.0  10.7 


45  II. 9 

9.4  14s 


8.6 
7.8 


1294  . 


5-3 

S.ij 
8.5 
9.6; 


3.2  2.7  17.0 

5.8,  4  3  15.6 

7.9  45  11.7 

12.3  3.3     8.0 


1.27 


0.70 


6.130.3  2.2  2.2  6 
3.0:18.7  4-4  4-3  9 
1 .4110. 2  8.1  6.912 
0.9|   5.2  10.  2  II  .8  14 


S  8.1     5.1  3 

4  7.8,   9.8  4. 

3  6.3  12.1  3. 

8  6.613.3  I 


6.4 


1.132; 

I.I35[ 

993 


3.7  8.4 
2.4  10.5 
1.4  II. 3 


4.6 


1-9 
4-3 


2.1  55 
3-1  9.4 
8.0  10.7 


8    4. 


121S  1456  1 .02  0.81 
j....     847 o.ss 


1496  ....  0.88 


72s    0.310.8.  7.6    6.915.611.4 


Miners,  coal:* 
25  to  34  years. 
35  to  44  years. 
45  to  54  years. 
55  to  64  years. 


Oils,  essential  and  volatile 
workers 

Oil-cloth  and  artificial 
leather  makers 


151' 
182J 
319 
407 


J11.9 

I12. 1 

6.6 


I 

1.5  o. 

2.7  I . 

3-4  4. 


7     4-4i    7.4 
6    6.6  10.4 


l.S    2.0  61.3 

3.1  1.9  47.0 
4.1)    1.6  27.3 

6.2  1.2  13.9 


1.5 
6.6 


I     8.8  14.7     7.8 


■  2  43-71 
.2  30.2 
.2'IS.7 


3.4    6.9     7-6  10.8  II. 3  II. 5    0.7     9.3 


778! 


.  .j0.69| 

..  1.38 


•  Compiled  from   mortality  statistics  of  the    Metropolitan  Life   Insurance  Company,  New  York, 
published  September,  1915. 


OCCUPATIONAL    MORTALITY    AND    MORBIDITY    STATISTICS 


757 


Mortality  and  Morbidity  Statistics. — Continued 


Deaths  of  persons  at  least  lo  years  of  age  engaged  in 
certain  specified  occupations 


Per  cent,  of  all  causes  at  specified  age 


Occupation  and  age  at 
death 


All      1   ^ 


u  9 

^•3 


a"* 

°  l3 
Q.  rt 


No.  of 
days  of 
sickness 

per 
annum 
per  ICK) 
mem- 
bers' 


No.  of 
deaths 
per  lOO 
mem- 
bers' 


•3  '  i 


Opticians,  clock  and  watchj 

makers ' 

Painters  and  decorators.  . ' 
Painters,  glaziers    and 

varnishers 

25  to  34  years 

35  to  44  years 

45  to  54  years 

55  to  64  years 

Paper-box  factory  workers 
Paper-g  o  o  d  s     factory 

workers 

Pavers  and  asphalters . . . .  j 


Physicians  and  surgeons: 

25  to  34  years 

35  to  44  years 

45  to  54  years 

55  to  64  years 


Piano  and  muscial  instru- 
ment makers 

Picture  -frame    factory 
workers 

Plasterers 

Plate  printers 


Plumbers,    and    gas 
steam  fitters.  .  .  . 

25  to  34  years 

35  to  44  years 

45  to  54  years 

55  to  64  years 


and 


Porters    and    helpers    (in 
stores,  etc.) 

25  to  34  years 

35  to  44  years 

45  to  54  years 

SS  to  64  years 

Potters     and     pottery 
workers 


471 
7S6 
842 
733 


3-2137.2 
O.8J28.4 

0.7  17.3 
0.4'   9-8 


1-7 
3-4 
S.I 

7.5 


0.4 
4-1 
6.9 

II.  I 


45 

7.3 

9-7 

13. 5 


6.8^  S.S 
8.7'ii.2 
7.8|l3.4 
7.6'i6.2 


99 

184 
251 
301 


4.0  21.2     2. 
3.815.8     2. 

2.0   9.2    s. 


4.0 
3.3 
7.2 


o.7i  4.0  II. 3  10. o 


2711  4.8  43-2  i-Sj   2.6 

323'   2.5  35.9  2.8|    1.5 

213;    1. 914. 6  5.2'   8.0 

I3ii ii8.3  6.910.7 


264  1.538.3  0.4 
323  1. 231. 6'  1.9 
264:  1. 521. 6  4-5 
155    0.6  10.3    6.5 


0.8 
3.4 
1.9 

7.7 


6.l!l2.I 

5.4|i2.0 

7.61   8.0 

iS-ol  4.3 


S.S 
6.8 
12.2 
176 


4.0 

6.0 

16.7 

10.6 


4.0 
2.4 
3.3 

2.5 


16.8 
13.0 

II. O 

S-9 


7.1 
2.7 
3.6 
2.7 


II. I 
6.5 
S.6 
3.7 


7.4'  4.8  1. 5  II. 4 
l.ll  6.8!  3.1  10. S 
2.7  6.6  3-3  II. 3 
9.2    6.9 3.8 


6.1  10.2 
II-5|lI.S 
16.3  15.2 
14.8    9.7 


3.8 
6.8 
16.7 
14.8 


i-S 
2.2 
1-9 
1.3 


6.4 

S.6 

45 

II. O 


674 
1017 


..0.66 

.  .  .!o.72 


IS74 


827 
1317 


1.06 


1202  0.96 
0.88 


84s 

81S 
.738 
718 


loss 


0.880.5s 


836 


1214jO.81io.15 
...  o . 46 
0.52 


0.61 


9S7 


758        ETIOLOGY   AND    PROPHYLAXIS    OF    OCCUPATIONAL   DISEASES 


Mortality  and  Morbidity  Statistics. — Continued 


Occupation  and  age  at 
death 


Printers,    lithographers, 

and  pressmen 

25  to  34  years 

35  to  44  years 

4S  to  54  years 

55  to  64  years 


Professional  service, 
males : 

25  to  34  years 

35  to  44  years 

45  to  54  years 

55  to  64  years. . . . 


Deaths  of  persons  at  least  10  years  oi  age  engaged  in 
certain  specified  occupations 


All 
causes 


Per  cent,  of  all  causes  at  specified 


age 


Professional  service, 
females: 
25  to  34  years. ... 

35  to  44  years 

45  to  54  years 

55  to  64  years. 


Quarry  men    and    stone- 
breakers 

Rubber  goods  workers. . . 
Refiners  in  sugar  factories 

Railway    enginemen    and 

trainmen* 

25  to  34  years 

35  to  44  years 

45  to  54  years 

55  to  64  years 

Railroad  street  employees 


291 
328 
265 
168 


1192 
1329 
1567 
1712 


385 
293 
268 
196 


7  51-5 

432.6 

.9  22.3 

0.6    6.5 


5.7  33.6 

2.9'20.4 

1.9    9.9 
0.7    4-4 


S.5|37 

2.0[l6 

0.7I  7.5 
0.5!  7.7 


947 


Saddlers,  leather  workers. 

Sailors 

Saw  mill  workers 

Shoemakers,      see     boots 
and  shoemaker 


3.3 
3.5 


14.7 
24.9 
13.8 

.7.4 


>-.2 

X  w 

O  tj 


0.7 
5.5 
7.2 
9.5 


1.4    1.3 

3.2  4-5 

6.3  8.1 
95  10.8 


4-7 

15. 7 
20.9 

15. 8 


1.3 

6.1 

7.5 

10.2 


0.7    0.3 
1.7     1.2 
0.9    6 
5.3  13.8 


lu:::^ 


4.1 
8.2 

9.4 
14.9 


4-9 

7.2 

10.8 

IS. 7 


6.8 

8.5 

9.7 

II. 7 


1-3 

S 
10 
13.8 


55 
7.6 
8.3 
9-5 


5.7 
9.9 
7.8 
6.9 


4-7 
9.2 
5.2 

8.7 


4-7 
6.9 
9.2 
6.4 


3.4 

7.3 

10.2 

14.3 


3.3 

7.8 

12.3 

13.0 


2.9 
6.8 
9.0 

10.7 


2.0 

7.5 

9.. 

10.6 


No.  of 
days  of 
sickness 

per 
annum 
per  100 
mem- 
bers 1 


851 


4.1 
5.2 
I-S 
S.4 


4.6 
4.7 
3.6 
1.8 


4.1 
7.3 
4-5 
4.2 


14.4 
7.7 
6.2 
3-9 


3.6 
3.4 
3.7 
2.0 


S6.o 
28.3 
18.3 
16.0 


1496 
1028 
1443 


870 

684 
1278 
1179 

642 


No.  of 
deaths 
per  100 
mem- 
bers' 


o.s8 


O.S4 


0.88 

14940.90 
O.S4 


0.76 

0.49 
1.46 
0.73 

0.68 


0.83 


•  Compiled  from  mortality  statistics  of  the  Metropolitan  Life  Insurance    Company,  New  York, 
September,  1915. 


OCCUPATIONAL   MORTALITY    AXD    MORBIDITY    STATISTICS 
Mortality  and  ^SfosBiDiTY  Statistics. — Continued 


759 


Occupation  and  age  at 
death 


Deaths  of  persons  at  least  lo  years  of  age  engaged  in 
certain  specified  occupations 


Per  cent,  of  all  catises  at  specified  age 


All 


8 


;  Bo 


o  :  V> 


No.  of 
days  of 
sickness 

per 

annum 

per  loo 

nmn- 

bersi 


No.  of 
deaths 
per  lOO 
mem- 
ben> 


Steam-railroad  emp!oj-ees: 

2S  to  34  years 

35  to  44  years 

45  to  54  years 

55  to  64  years 


1382 

1133 

941 

724 


2.7  10. s'  0.7 


1.9 


9.2 
6.6 
3.2 


1-9 
5.3 
8.1 


0.9'  1.7 
1.2,  3.9 
35  5-8 
7.9  12.2 


2.6;   1.5'  I.2'67.J> 

4.4    2.7  2.556.3 

S.I    6.3  1.347.7 

5.7    9.1  1.030.2 


Servants  and  waiters . 

25  to  34  years 

35  to  M  years 

45  to  54  years 

55  to  64  years 


633 


Servants    and  waiters,] 
females: 

25  to  34  years 

35  to  44  years 

45  to  54  years 

55  to  64  years 


693! 

701 
644 
407 


2704 
2578 
2671 
2760 


2.9  40.4 
1.7  29.7 
0.8  20.2 
0.2,17.0 

i 


2.9  33. 
1.8  22. 
i.o  10. 
0.5    5. 


9  3. 
O  9 
2  14. 
5  13. 


,6  r 

3  I 

5  6 

61  8 


3  3 

4  9 
613 


3'  6.3J 

4  II. o 

7  14.6 

II. 8, 


.5  5.9 
.9  10. 1 
.1  12.9 
O  15. 7| 


7.4'  4 
7.8^  8. 
7.5  12. 
9. 6112. 


6.6  4. 
6.2  7. 
7.9  II. 
8.4  12. 


2  5.5 
4  3.9 
7  2.6 

3  2.S1 


7  2.0 

7  0.8 

3  0.7 

2  0.6 


771  0.67'o.27 


Storage  battery  workers 722;  1276 

Tailors 71S;   884 

25  to  34  years 326    2.137.7    2.1    1.5    6.1    7.4,   6.4    6.1    7.4 

35  to  44  years 415    2.733.7    4-3    i-7    8.0    5.8  10. i    6.3    3.4 

45  to  54  years 456    0.916.7    8.1    6.1    9-9    8.110.1    4.6    4.8 

55  to  64  years 361 6.913.6    8.313.6    9.412.2    4.713.6 


Tallow  and  soap  factory 

workers 

Tanners  and  leather  dyers. 

Teachers  and  professors  in 

colleges,  etc.,  females: 

25  to  34  years 

35  to  44  years 

45  to  54  years 

55  to  64  years 


269  6.338.7 

194  3.1  19. 1 

167  1.2!   7.8 

130  0.8I  7.7 


Terra     cotta     and     brick 

workers I 

Textile  mill  workers*.  .  .  .         2390  ......... 

25  to  34  years S.3'47.S 

35  to  44  years 1.3  37.7 

45  to  54  years 1.5  18.0 

55  to  64  years 0.8    8.9 


1. 5 
4.1, 
7.8 


S.2 
9.3 

8.4 


16.2     6.910.0 


5.2 
II. 9 

7.2 
II. S 


2.6 

7.2 

9.0 

10. 0 


3-3 

1.5 
3.6 
2.3 


1049 


,4  0.4    S.7|  4.3|   2.51  1.4    5.7 

3  1.0    5.5]   9.0    7.I1  10    6.8 

4.8  5-8  10.3    6.3  12.5  3-5    4-S 

7.1  9-9  17.0    57  12. I  1.4:   34 


III8 


876 


0.600.55 
0.880.56 


ti4 


0.46 


0.89 

l229!o.83 


O.sS 


•  Compiled  from  mortality  statistics  of  the  Metropolitan  Life  Insurance  Company,  New  York, 
published  September,  1915. 


760        ETIOLOGY   AND    PROPHYL.AXIS    OF   OCCUPATIONAL   DISEASES 


Mortality  axd  Morbidity  Statistics. — Continued 


Occupation  and  age  at 
death 


Deaths  of  persons  at  least  10  years  of  age  engaged  in 
certain  specified  occupations 


All 
causes 


Per  cent,  of  all  causes  at  specified  age 


'E'cS 

o  S3 

Q.  ea 


go 

C  cii 


No.  of 
days  of 
sickness 

per 
annum 
per  100 
mem- 
bers' 


No.  of 
deaths 
per  100 
mem- 
bers 1 


Tin    plate     and 

makers 

25  to  34  years. 
35  to  44  years. 
45  to  54  years. 
55  to  64  years. 


Tobacco  and  cigar  factory 

workers 

25  to  34  years 

35  to  44  years 

45  to  54  years 

55  to  64  years 


Typefounders, 

stereotypers 

Typesetters  and  composi- 
tors  


7.6 


681 

92 

120 

134 
136 


9821 

136J   S-i 

l8i| 

233; 

187    O.S 


Trade  and  transportation, 
males: 

25  to  34  years 

35  to  44  years 

45  to  54  years 

55  to  64  years 

Trade  and  transportation, 
females: 

25  to  34  years 

35  to  44  years 

45  to  54  years 

55  to  64  years 

Upholsterers 

Veneer  factory  workers. . . 


37-0 

32.  S 

17.9 

7-4 


I .  I 
3.3 
7-5 
9.6 


49-3 
33.7 
23.2 


79481   4-4'3i-9 
82191   2.4  22.8 


8333 

7495 


1.3 
0.6 


12.3 
5.8 


1.4 
3.3 
7. 
9.6 


66?!  4-3  39-9 
348.  1. 416. 1 
207     1.4J   7.7  I 

I2I|    0.8      2.5   14.9 


Watchmen,  policemen, 
firemen,  etc.: 

25  to  34  years 

35  to  44  years 

45  to  54  years 

55  to  64  years 


190 
315 

527]   2.1 
6S7    0.3 


1124.2 

S  17.8 

9-S 
4-9 


Waiters i 

Weaving  mill  operatives.  . 

Wicker   ware   and   basket 

workers 


1.6 
1-9 
8.2 

7-5 


1-7 
6.7 
5-9 


8.7 

6.7 

13.4 

IS. 4 


S.4 
8.3 
9.0 

7.4 


4-3 

S.8 

9.0 

13.2 


5-4  IS. 2 
1-7  13-3 
3.7  9.7 
2.9    6.6 


4.4 


2.9 

12.2 


6.6 
6.1 


4.4 
3-3 


3. oil. 2!  6.9    9.0 
7.0111.8    4.8  19.3 


6.2 

[O.S 


4-7 

8.0 

10.8 

IS.O 


6.S 
8.7 
7.8 
7.3 


S-i 

4./* 

S.2 

4-3 


S.I 
7.7 
S.6 
2.7 


3.3  20. 5 
3-9  IS.8 
3-4JI2.3 
2.0    7-S 


0.9    6.4    3.6  5.2 

4.0  10. 1    4.9  8.0 
6.8    8.7]   9.2I  9.2 

9.1  19.0  17.4  8.3 


2.1 
2.5 
6.8 
9.9 


3.1 
1-7 
O.S 


4.2 

9.2 

IS. 6 

18.2 


6.8 
8.3 
6.8 
7.8 


30 
5.2 

2.4 
1.6 


5.8 
6.7 
II. 4 
12.3 


4-7 
6.0 
4-7 
3.S 


21. 1 
14.6 

11. 2 
8.4 


824 


909  1158  1.440.95 


1064 


iiSS 


1 108  (?) 


. .  0.83 


720 
IIS4 


0.89 

(?) 


0.69 
.0.88 


633    771 
SS7 


0.67  0.27 
0.7s 


OCCUPATIONAL   MORTALITY  AND   MORBIDITY   STATISTICS. 


761 


Mortality  and  Morbidity  Statistics. — Concluded 


Occupation  and  age  at 
death 


Woodworkers: 
25  to  34  years. 
35  to  44  years. 
45  to  54  years. 
55  to  64  years. 


Yeast  factory  workers. 

Other     miscellaneous 
dustries: 

25  to  34  years 

35  to  44  years 

45  to  54  years 

55  to  64  years 


Deaths  of  persons  at  least  10  years  of  age  engaged  in 
certain  specified  occupations 


All 
causes 


Per  cent,  of  all  causes  at  specified  age 


197 
201 
264 
248 


571 
566 
604 
523 


2 .  o  40 . 6 
2.525.4 
18.6 
0.4I11.3 


5.4 
2.5 
1.7 
0.2 


30.6 
23.3 
13.6 

7. 


■§ 

» 

!>.'^ 

sa 

■-a 

'E'ca 

t. 

0  1- 

a2 

<0 

<;u. 

w 

SB 


i.o   3.6 
3.0  10. o 


,6    2.S    6.6  18.3 
8.5    7.017.4 


7.2I  4.2,10.2    8.7  io.6|  3.4 
9.7  10.9  16.5    4.4110.91  3.6 


1 .2 
30 
6.3 
9.6 


1.6 

3.0 

6.8 

10. S 


5.8 

6.2 

8.9 

16.8 


2.3  4.: 

7.2J  3-: 

9. 91  4< 

8.8  2.; 


12.9 
6 


21.9 
16. 
12.7 
6.1 


No.  of 
days  of 
sickness 

per 
annum 
per  100 
mem- 
bers" 


863 


No.  of 
deaths 
per  100 
mem- 
bers' 


..0.48 


PART  III 

THE  RELATION  OF  HOSPITAL  AND  MEDICAL 
SCHOOL  WORK,  STATISTICS,  GOVERN- 
MENT STUDY  AND  LEGISLATION 
TO  OCCUPATIONAL  DISEASE 


DIVISION  I 
The  Function  of  Clinics  in  the  Prevention  of  Occupational  Diseases 

CHAPTER  I 

THE  MILAN  CLINIC  FOR  OCCUPATIONAL  DISEASES.    ITS  ORIGIN, 
PURPOSES  AND  ACTIVITIES 

BY  PROF.  DR.  L.  DEVOTO.  Milan,  Italy 

The  Milan  Clinic  for  Occupational  Diseases  is  unique  at  present  in  the 
scientific  world,  and  marks  a  period  of  great  historic  importance  in  modern 
Italian  life. 

Since  the  very  first  days  of  the  reign  of  Victor  Emanuel  III,  public  opinion 
has  been  interested  in  vital  hygienic  and  social  problems.  Much  has  been 
said  on  malaria  and  the  Roman  waste-lands;  on  pellagra  and  the  work  in  the 
rice  fields  and  in  the  mines;  on  woman's  and  children's  work;  on  Government 
inspection  of  labor;  on  accidents  in  general;  and  on  assistance  to  invalids 
and  to  the  aged  poor. 

The  discussions  were  so  wide  and  conclusive  as  to  gain,  between  the  years 
1901  and  1902,  the  approval  by  Parliament  of  a  series  of  social  laws  intended 
to  remedy  those  painful  conditions. 

It  was  in  that  period  that  the  city  of  Milan  elaborated  comprehensive 
regulations  imposing  on  the  city  factories  those  strict  hygienic  rules  that 
later  were  highly  commended  by  the  Government,  and  by  the  administration 
of  other  cities.  Then  followed  the  foundation  of  several  institutions  in 
Milan,  which  afforded  physicians  the  opportunity  of  perfecting  and  specializ- 
ing their  knowledge;  among  these  is  the  Clinic  for  Occupational  Diseases. 

The  purposes  of  the  Clinic  are  as  follows:  To  study  scientifically  the 
causes  of  occupational  diseases  and  to  spread  its  clinical  knowledge  among 
physicians;  to  gather  in  the  Clinic  all  workmen  apparently  or  decidedly 
affected  by  occupational  diseases,  whether  in  incipient  or  advanced  stage,  for 
the  purposes  of  diagnostical  and  therapeutical  experiments,  and  to  examine 
systematically  the  health  conditions  of  workmen  engaged  in  industries  of  all 
kinds,  and  especially  those  working  in  unhygienic  occupations. 

After  two  years  of  political  vicissitudes  the  Italian  Parliament  passed  a 
law  recognizing  the  Industrial  CUnic  Institutions  as  "Post-University" 
and  authorizing  them  to  award  diplomas. 

In  the  year  1906  the  First  International  Congress  of  Occupational  Diseases 
was  held  in  Milan  and  was  a  great  success.  This  Congress,  appreciating  the 
vast  importance  of  the  industrial  clinic-hygiene  problems,  suggested  that  the 
city  secure  larger  ground  for  the  erection  of  the  Clinic  than  was  intended  and 

.765 


766  THE   PREVENTION   OF    OCCUPATIONAL   DISEASES 

more  means  to  provide  it  with  a  stronger  scientific  organization,  which  caused 
another  delay. 

Finally  in  the  month  of  December,  1907,  the  laying  of  the  corner-stone 
took  place,  and  the  building,  completely  finished,  was  inaugurated  March 
20,  1910. 

The  administration  of  the  Institutes  was  entrusted  to  a  Council  of 
Members. 

Calling  me  to  the  Directorship  of  the  CHnic  in  1906,*  the  city  of  Milan 
gave  me  power  to  enter  agreements  for  the  construction  and  disposition  of 
the  building  which  has  since  been  erected  in  an  area  of  5000  square  meters, 
actually  covering  a  surface  of  1500  square  meters  in  the  center  of  the  hospital 
district  of  Milan,  and  not  far  from  the  leading  labor  establishments. 

The  Clinic  consists  of  three  buildings,  which  include: 

Five  dispensary  rooms,  also  used  for  consultation. 

Eight  infirmaries  and  six  isolating  rooms  of  the  capacity  of  no  beds  with 
the  necessary  smaller  rooms  used  for  first  analysis. 

Three  physiopathological  laboratories  and  one  room  for  the  study  of 
experimental  fatigue. 

Three  bacteriological  laboratories. 

Five  chemical  laboratories. 

Five  pathological,  histological  and  microscopical  laboratories. 

One  auditorium  for  200  physicians  and  three  demonstration  rooms. 

One  large  library. 

One  archives  room. 

Three  Rontgenological  laboratories. 

Five  rooms  for  the  Professional  Hygiene  and  Pathology  Museum. 

One  refrigerator  room. 

One  anatomic  museum  room. 

One  autopsy  room. 

The  idea  of  having  the  autopsy  and  anatomic  museum  rooms  in  the  same 
institute  is  worthy  of  the  highest  praise;  it  makes  research  easier  and  enables 
physicians  taking  the  courses  or  working  in  the  Clinic  not  only  to  watch 
the  autopsy,  but  also  to  follow  all  the  further  investigations  required  for  the 
anatomical  diagnosis. 

The  laboratories  have  proved  to  be  of  great  value  to  the  Clinic  not  only 
for  clinical  study  but  also  for  experimental  and  anatomopathological  studies. 
It  is  now  more  and  more  realized  that  it  would  have  been  useless  to  establish 
a  Clinic  which  represents  a  departure  from  trodden  paths,  and  which  faces, 
besides  its  difficult  problems,  a  considerable  amount  of  public  diffidence, 
without  furnishing  it  with  an  abundance  of  scientific  material.     Better  not 

*  When  in  the  year  1901  I  was  a  Professor  of  Internal  Pathology  at  the  University 
of  Pavia,  I  initiated  a  clinical  course  on  Occupational  Diseases  which  proved  very  successful, 
and  started  the  publication  of  a  review  of  Industrial  Physiolog>',  Pathologj'  and  Hygiene, 
by  the  title:  "IlLavoro"  ("Work")  I  left  the  University  of  Pavia  in  1906  when  the  opening 
of  the  Clinic  was  approaching. 


MILAN   CLINIC   FOR   OCCUPATIONAL   DISEASES  767 

do  anything  than  bring  into  existence  an  ill-appointed  institution,  especially 
in  a  city  like  Milan,  where  neither  a  Faculty  nor  clinical  facilities  existed, 
and  where  there  were  no  laboratories  available. 

Without  counting  the  services  kindly  rendered  by  city  officials,  engineers, 
assistants  and  by  all  of  the  civil  service  workshops,  the  Clinic  has  cost  over 
1 ,000,000  Hres,  though  the  estimated  expenditure  called  for  a  much  smaller  sum . 

As  for  me,  who  took  upon  myself  a  part  of  the  responsibility  for  this 
excessive  expenditure  in  the  building  of  the  Chnic,  I  feel  that,  if  this  attitude 
of  mine  has  been  wrong,  there  is  but  one  way  for  me  to  make  reparation, 
and  that  is  to  do  all  I  can  to  make  the  Clinic  as  useful  as  possible  to  the 
workers  of  INIilan. 

As  things  are  now,  only  one-half  of  the  no  beds  that  the  Clinic  provides 
can  be  occupied,  but  I  believe  that  we  will  have  all  the  beds  of  the  Clinic 
in  use  as  soon  as  the  Compulsory  Insurance  Act  becomes  a  law  in  Italy,  as 
it  has  in  other  countries.* 

Some  of  the  Members  of  the  Faculty  were  my  colleagues  at  the  University 
of  Pavia,  some  were  assistants  in  other  Italian  or  foreign  universities,  and 
all  have  had  ample  opportunity  to  deepen  their  studies  in  the  particular 
branches  that  they  had  chosen  and  in  which  they  were  called  here  to  lead  and 
to  teach  or  assist  the  36  young  physicians  for  whom  there  are  positions. 

Ever  since  the  opening  of  the  Chnic  I  deemed  it  necessary  to  establish  a 
special  and  active  propaganda  of  hygiene  among  the  working  classes.  The 
results  obtained  are  indeed  remarkable. 

The  work  is  conducted  in  the  following  manner : 

1 .  By  cUnical  teaching  to  physicians. 

2.  B}^  the  treatment  of  the  patients  admitted  in  the  Clinic. 

3.  By  scientific  work  in  the  field  of  occupational  pathology. 

4.  By  consultations  with  and  examinations  of  workmen;  also  by  exer- 
cising a  general  control  of  their  health  and  conditions. 

5.  By  inspections  and  investigations. 

6.  By  a  popular  propaganda  of  occupational  hygiene. 

Rather  than  stop  to  say  more  in  a  general  way  on  these  activities,  I 
will  relate  how  they  have  been  appHed  in  these  first  few  years  of  the  existence 
of  the  Clinic. 

I.  DIDACTIC  ACTIVITY  OF  THE  CLINIC 

For  the  Chnic  to  undertake  the  task  of  teaching  physicians  the  treatment 
and  prevention  of  diseases  such  as  the  so-called  saturnism,  mercurialism, 
anilinism,  phosphorism,  etc.,  and  of  all  other  occupational  intoxications,  in- 
cluding professional  infections  (anchylostomiasis,  carbuncles,  etc.)  the  neurosis 
due  to  mechanical  work,  caissonism,  pneumokoniosis,  and  miner's  phthisis,  is 
only  natural.  But  a  Clinic  establishment  for  the  purpose  of  diminishing  the 
antiphysiologic  factors  of  labor,  for  instructing  physicians  in  that  Une,  and 

*A  compulsory  accident  insurance  law  was  passed  in  1898  and  amended  in  1903.  A 
compulsory  maternity  insurance  law  was  passed  in  19 10.  A  voluntary  sickness  insurance 
and  for  old  age  insurance  exist,  the  latter  is  compulsory  for  some  of  the  government  em- 
ploj-ees,  but  so  far  no  compulsory  health  insurance  system  has  been  adopted  in  Italy. 


768  THE    PREVENTION    OF    OCCUPATIONAL   DISEASES 

for  awarding  diplomas  has  another  field  of  action,  which  is  less  definite,  as 
yet,  but  much  more  important.  It  is  the  valuation  of  the  occupational  factor, 
often  concealed,  which  must  be  more  deeply  considered.  When  this  is  dis- 
covered, then  the  steps  for  prevention  can  be  more  easily  taken.  Here  are 
some  of  the  points  which  are  frequently  used  as  cHnical  illustrations  and  which 
lead  us  to  affirm  strongly: 

(a)  That  the  relation  between  continual  efifort  and  alteration  of  the  heart 
and  of  the  blood-vessels  is  closer  than  generally  beUeved. 

(b)  That  healthy  persons  who  undertake  hard  work,  without  having  the 
adequate  physical  resistance,  are  bound  to  suffer  alteration  or  displacement 
of  some  organs. 

(c)  That  some  visceral  localizations  of  syphilis  are  related  to  abuse  of 
strength;  to  local  traumas. 

{d)  That  hard  labor  may  hinder,  in  workmen  who  have  recently  recovered 
from  infective  diseases,  the  restitution  of  normal  functions  of  those  organs 
which  were  involved  by  the  infection  (myocardium,  lungs). 

(e)  That  a  loose  technical  appreciation  of  the  health  conditions  of  boys 
and  girls  licensed  to  work,  may  cause  serious  disturbances. 

(/)  That  a  wholesome  occupation  may  still  cause  disturbances  if  the  en- 
vironment is  unhygienic  (dampness,  poor  light,  insufficient  air). 

(g)  That  work  requiring  strained  positions  must  be  done  in  short  periods, 
alternated  by  exercise. 

(h)  That  occupational  infantilism  occurs  oftener  than  it  is  believed. 

(i)  That  labor  is  to  be  considered  as  a  factor  capable  of  forming  special 
clinical  pictures. 

Legislators  may  distinguish  between  diseases  arising  undoubtedly  from 
work  through  poison  and  those  due  to  the  diffusion  of  bacteria,  or  those 
caused  by  intermittent  or  contingent  factors,  but  we,  as  physicians  who  must 
look  at  diseases  especially  from  the  viewpoint  of  their  cure,  and  above  all  of 
their  prevention,  and  who  live  outside  the  pale  of  mere  speculation,  have  no 
doubt  that,  admitting  the  necessity  of  an  institute  for  this  specific  study 
and  teaching  and  for  the  prophylaxis  of  labor  diseases,  it  is  the  task  of  such 
a  Clinical  Institute  and  of  its  Staff  to  make  researches  for  and  seek  the  demon- 
stration of  the  agent  creative  of  the  diseases,  inasmuch  as  it  is  centered  in 
antiphysiological  and  antihygienic  work. 

I  am  also  hopeful  that,  little  by  little,  the  Faculty  of  the  University  Med- 
ical CHnics  will  come  to  see  the  necessity  of  helping  their  students  to  look  at 
diseases  from  the  point  of  view  of  the  social  influence,  and  to  give  them,  be- 
sides the  ordinary  clinical  lessons,  those  lessons  that  have  far-reaching  social 
import. 

The  young  physician  and  the  student,  if  taught  to  analyze,  with  an  ob- 
jective, unbiased  criticism,  the  causes  contributing  to  the  pathogenic  forces 
bad  surroundings  or  unhygienical  work,  will  certainly  become  a  good  clinic 
physician  as  well  as  a  good  social  worker. 


MILAN    CLINIC    FOR    OCCUPATIONAL    DISEASES  769 

The  official  lessons  of  the  Director  of  the  Clinic  are  public.  They  begin 
November  i,  and  end  June  15.  During  the  fall  vacations,  and  also  during 
the  school  year,  rapid  courses  of  professional  pathology  and  hygiene,  of 
tuberculosis,  pellagra,  diagnosis,  and  the  use  of  X-rays,  are  given,  with  the 
assistance  of  Professors  attached  to  the  Clinic. 

The  fees  range  from  40  Hres  (without  laboratory)  to  480  (including  labora- 
tory) a  year. 

To  obtain  a  diploma,  the  student  must  have  attended  all  the  courses  of  the 
Clinic  for  no  less  than  12  months,  write  an  original  thesis  on  an  argument 
in  harmony  with  the  ultimate  purposes  of  the  Clinic,  and  pass  a  practical 
clinic  examination,  and  a  theoretical  test  as  well. 

The  graduates,  up  to  now,  number  ten,  and  ten  others  are  preparing  their 
theses.  The  number  of  physicians  who  have  attended  the  lessons  and  who 
have  done  work  in  the  laboratories  and  dispensaries  is  380. 

Out  of  the  funds  donated  to  the  Clinic,  it  is  possible  for  the  Administration 
to  award  small  scholarships  to  those  civil  service  doctors  who  wish  to  complete, 
by  clinical  observation  and  laboratory  research,  the  study  of  the  cases  of 
professional  pathology  which  they  meet  in  their  daily  practice. 

2.  ASSISTANCE  TO  PATIENTS 

Workmen  affected  by  direct  or  contributory  causes  arising  from  their 
occupations  are  taken  in  the  Clinic:  (a)  to  be  treated;  (b)  to  establish  a 
diagnosis,  when  it  is  not  possible  to  do  so  in  the  dispensary;  (c)  for  teaching 
purposes  (and  I  wish  to  say  here  that  our  working  people  willingly  submit 
to  such  examinations  when  requested)  although,  whenever  it  is  possible,  we 
prefer  out-patients. 

The  Clinic  rooms  are  very  well  aired,  ventilated,  heated  and  dusted 
(vacuum  cleaner),  and  every  bed  has  about  1200  cu.  ft.  of  air-space;  every 
ward  has  its  own  analysis  room. 

It  is  superfluous  for  me  to  enter  into  the  details  of  the  different  methods  of 
treatment,  for,  as  may  be  easily  understood,  they  vary  so,  some  being  of  a 
pharmacologic  order,  some  of  a  physical  order,  etc.,  but  I  wish  to  say  this, 
that  all  patients  and  their  relatives  are  provided  with  a  detailed  account  of 
the  disease,  and  every  person  who  is  discharged  from  the  Clinic,  besides  the 
better  health  that  it  has  been  possible  to  give  him,  also  has  the  privilege  of 
taking  with  him  a  good  knowledge  of  hygienic  rules  which  he  may  profitably 
impart  to  his  fellow-workers. 

As  a  general  rule,  people  affected  by  pulmonary  tuberculosis  are  not  ad- 
mitted. Only  for  special  didactic  purposes  are  patients  affected  by  pneu- 
mokoniosis  and  eventual  tubercular  processes  admitted  to  the  Clinic,  and 
these  are  placed  in  the  isolation  rooms. 

The  most  important  dispensary  cases  which  have  presented  themselves 
during  the  week  are  reviewed  each  Saturday  and  briefly  discussed  for  the 
benefit  of  the  physicians. 
49 


770 


THE   PREVENTION    OF    OCCUPATIONAL   DISEASES 


The  Clinic  offers  to  its  patients  a  large  garden  and  several  terraces.  This 
is  not  the  ideal.  Italy,  so  far,  has  no  convalescence  or  "Erholung,"  places 
as  the  Germans  have  it,  and  something  of  that  sort  is  needed  for  a  Clinic 
which  treats  persons  affected  by  apical  catarrh,  poor  blood,  states  of  neurosis, 
alterations  of  the  cardiovascular  apparatus,  paralysis,  etc.,  but  I  hope  that 
in  the  near  future  we  may  have  some  ideal  cHmatic  balneological  station  on 
the  lake  of  Garda  (90  minutes  from  Milan).  The  owner  of  the  Sirmione 
Station  has  already  ofifered  the  Clinic  a  large  piece  of  ground  for  that  purpose, 
and  if  the  plan  can  be  carried  out,  the  Station  will  remain  open  all  the  year 
round.  In  that  vicinity  there  is  also  a  spring  of  chlorosulphuric  water, 
something  like  that  of  Aix-La-Chapelle,  which  is  very  good  for  cases  of  lead 
intoxication.  The  delightful  climate  of  the  spot  would  make  the  Station  all 
the  more  beneficial. 

3.  SCIENTIFIC  PRODUCTION 

The  Clinic's  scientific  production  consists  of  researches,  the  findings  of 
which  are  made  known  widely,  so  as  to  obtain  the  views  of  all  physicians 
and  institutions  working  in  other  fields,  as  well  as  those  of  the  city  doctors. 
The  patients  coming  to  the  dispensary  or  received  in  the  Clinic  fre- 
quently offer  splendid  material  for  special  research.  I  will  here  give  a 
short  account  of  what  has  been  done  up  to  the  present  time  and  of  the 
results  attained. 

Overexertion  has  been  the  object  of  many  laboratory  researches  which 
are  conducted  as  follows:  histo pathologically  by  Cesa  Bianchi,  experimentally 
by  Ciovini,  inimunitarily  by  Vallardi,  and  chemically  by  Preti;  all  these  led 
us  to  ascertain: 

1.  That  work,  even  when  very  hard,  does  not  produce  immunitary  re- 
actions. 

2.  That  hard  work  originates  alternations  of  the  cardiac  muscular  fibers 
which,  if  not  extremely  serious,  may  be  repaired  by  rest  and  good  nourish- 
ment, but  which  are  otherwise  irreparable.  The  suprarenal  capsules  are 
also  subject  to  alteration  by  hard  work. 

3.  That  hard  work  generates  a  conspicuous  neutrophilic  polynucleosis 
connected  with  a  transient  disorder  of  the  blood  gases  (excess  of  carbon 
dioxide)  caused  by  a  function  of  the  leucocytes  versus  carbon  dioxide. 

4.  That  from  hard  muscular  work  there  arises  a  production  of  acetone 
and  also  an  increase  of  the  antitryptic  power  of  the  blood  serum,  and  that 
in  another  kind  of  muscular  exertion,  in  the  excitement  of  persons  mentally 
affected,  a  remarkable  elimination  of  uric  acid  is  noted. 

5.  That  periods  of  great  strain  in  working  people  (harvest  time)  lead  to 
prostration  of  the  strength  and  pressure  of  the  heart. 

Dusts  were  made  the  object  of  special  experimental  studies  by  Prof.  Cesa 
Bianchi  and  myself,  and  this  is  our  point  of  view:    ' 


MILAN   CLINIC   FOR    OCCUPATIONAL   DISEASES  771 

(a)  By  causing  animals  to  inhale  dust  we  have  produced  only  pulmonary 
tuberculosis,  regardless  of  the  way  in  which  the  tubercular  germ  is  introduced, 
while  without  the  use  of  dust  general  tubercular  processes  result. 

(6)  Dusty  trades  frequently  produce  acoustic  reactions  of  the  pulmonary 
apexes  which  look  like,  but  are  not,  the  result  of  a  tubercular  process.  The 
germ  of  tuberculosis  will  later  thrive  because  dusts  have  prepared  the  soil 
for  it. 

Chronic  poisoning  derived  from  lead  inhalation  has  been  studied  from 
dififerent  points  of  view,  and  we  are  in  a  position  to  say  that  the  first  altera- 
tions come  from  disturbances  of  a  chemical  order  (production  of  uric  acid 
on  account  of  prevented  uricolysis  or  of  uric  reconstruction)  and  from  altera- 
tions of  cellular  elements  to  which  lead  adheres  more  durably,  both  in  its 
passage  and  during  its  ehmination,  and  because  of  an  attraction  of  the  said 
cellular  elements  toward  lead,  whether  alcohol,  exertion,  light,  etc.,  are 
contributory  or  not,  they  prepare  the  way  under  the  progressive  march  of 
intoxication,  for  vasal  alterations  and,  with  or  without  these,  but  aided 
by  other  circumstances,  as,  the  habit  of  unusual  effort,  damp  or  antihygienic 
environment,  insufficient  or  irrational  nourishment,  wine,  liquors,  tobacco, 
and  common  diseases,  the  condition  progresses  and  we  enter  into  the  realm 
of  real  saturnism,  that  is,  into  that  large,  complete  and  complex  range  of 
phenomena  which  has  caused  lead  to  be  called  the  poison  of  protoplasm  on  a 
large  scale. 

In  studying  pregnancy  cases  of  varnishers'  wives  in  the  Clinic,  it  has  been 
ascertained  that  the  mortality  of  the  descendants  is  49.7  per  cent.,  and  the 
occurrence  of  abortions  has  been  calculated  as  10.3  per  cent. 

As  to  phosphorism,  Dr.  Vallardi,  who  had  the  opportunity  to  study  about 
50  cases  of  phosphoric  necrosis,  made  experimental  researches  that  lead  us 
to  state: 

1.  The  pathognomonic  manifestation  of  chronic  phosphorism  in  the 
human  body  is  shown  by  the  necrosis  of  the  jawbone. 

2.  The  other  symptomatical  manifestations  especially  frequent  among 
workmen  who  are  always  in  contact  with  phosphorus  have  no  specific 
characters. 

3.  It  is  not  possible  to  reproduce  in  animals,  poisoned  chronically  with 
phosphorus,  a  phenomenon  resembling  nearly  enough  that  which  appears  in 
the  necrosis  of  man's  jawbone. 

4.  On  the  contrary,  chronic  poisoning  of  animals  by  phosphorus  through 
the  respiratory  or  the  gastric  channels  or  by  both  ways  simultaneously  pro- 
duces modifications  of  the  blood  crasis,  injuries  of  the  glandular  parenchyma, 
of  a  degenerative  type  (especially  of  the  liver),  and  constant  alterations  of 
the  material  exchange. 

None  of  these  manifestations,  considered  by  itself,  can  be  regarded  as 
specific. 

The  Clinic  has  had  about  100  cases  of  pellagra  in  these  past  years,  and 


772  THE   PREVENTION   OF    OCCUPATIONAL   DISEASES 

from  the  study  made  of  this  disease  we  are  led  to  admit  that  there  is  no  pella- 
gra without  maize  (corn). 

In  conformity  with  the  views  expressed  by  me  years  ago  about  the  paresis 
appearing  in  cases  of  pellagra  in  those  nervous  centers  of  the  muscles  which 
have  been  most  burdened  by  work,  we  have  gathered  much  data,  proving  that 
intense  work  reacts  back  to  an  isolated  or  separated  center,  to  which  are 
attracted  those  factors  of  diseases  which  may  eventually  affect  this  special 
center  or  organ:  in  fact,  lead  selects  the  most  strained  parts,  to  exercise  on 
them  its  paralyzing  power;  spirochaeta  chooses  the  aorta  in  those  persons  who 
overstrain  themselves;  the  ectopic  kidney  becomes,  in  persons  who  work 
standing,  the  seat  of  unilateral  nephritis;  the  radiocarpic  articulation,  in  per- 
sons who  have  an  occupation  limiting  their  exercise  within  certain  fixed  mo- 
tions, becomes  the  center  of  arthritis,  and  the  radial  and  ulnar  arteries  harden 
in  persons  making  great  efforts  with  the  respective  joint  (stone  workers, 
filers,  blacksmiths,  etc.). 

Under  a  different  aspect  persons  working  in  a  bended  or  crouching  position 
daily,  and  for  long  hours  (as  brass  and  tin  workers,  and  others),  often  complain 
of  pains  in  the  lumbar  region  which,  at  first,  seem  to  be  lumbago,  but  which 
are  really  due  to  an  alteration  of  the  spine,  a  real  anchylosis  induced  by  work 
done  in  one  continual  position,  and  by  the  circulatory  and  trophic  disturb- 
ances due  thereto. 

In  order  to  keep  this  review  within  limits  I  will  only  note  that  boys  who 
have  been  engaged  in  hard  work  since  childhood  are  frequently  subject  to 
infantiHsm.  The  Clinic  has  had  several  cases  of  infantilism  which  can  be 
used  as  appropriate  illustrations  of  the  above  statement. 

A  fund  for  scientific  research  has  been  provided  by  the  contributions  of 
the  King  of  Italy,  of  his  Government,  of  several  Italian,  English  and  American 
philanthropists,  and  of  the  working  people  of  Milan. 

4.  CONSULTATIONS  WITH  THE  WORKMEN 

Free  consultations  are  given  every  day  from  10  to  12.30  to  those  who  give 
evidence  of  being  poor  and  hard-working  people.     They  come: 

1.  To  be  assured  as  to  their  personal  organic  condition  and  physical 
fitness  to  learn  a  certain  trade,  to  keep  the  one  they  have,  or  to  enter  into  a 
new  one. 

2.  To  learn  rules  and  to  get  medical  hygienic  instructions  about  the 
occupation  in  which  they  are  engaged. 

3.  For  a  periodical  medical  inspection  aiming  at  an  early  recognition  of 
those  preliminary  disturbances  that,  directly  or  indirectly,  arise  from  their 
occupations. 

4.  To  have  a  diagnosis  made  and  methods  of  treatment  suggested  for 
diseases  already  existing.  During  this  free  consultation  service  all  the  phy- 
sicians on  the  Staff,  each  in  his  laboratory,  are  at  the  disposal  of  the  consult- 


MILAN    CLINIC   FOR   OCCUPATIONAL   DISEASES  773 

ants,  so  that  whatever  examination  is  called  for  in  the  different  cases  (blood 
spitting,  urine,  X-ray  examinations,  acute  reactions,  punctures,  electro-diag- 
nosis, serum  diagnosis,  etc.)  can  be  promptly  performed  and  all  other  aids 
such  as  measuring,  photographs,  etc.,  which  may  be  useful  to  illustrate 
the  case,  can  be  provided  for  without  delay.  If  the  diagnosis  is  made  at  one 
sitting  the  patient  is  instructed  in  all  hygienic  or  medical  rules  required  by 
his  condition;  when  the  diagnosis  is  not  possible  at  first  consultation,  and 
when  the  treatment  cannot  be  followed  at  home,  patients  are  received  into 
the  Clinic. 

Those  affected  by  lead  colic  are  immediately  taken  in,  for  the  following 
reasons: 

1.  In  the  patient's  home  there  is  lead  undoubtedly,  which,  penetrating 
the  system,  would  make  the  crisis  longer  and  still  more  serious. 

2.  It  is  necessary  to  free  the  patient  from  his  clothes  which  are  usually 
dirty.  He  is  then  shaved  and  his  hair  and  nails,  where  lead  always  collects, 
are  cut. 

3.  Soon  after  that  a  very  hot  bath  is  given  the  patient,  a  treatment  of 
pilocarpine  is  started  by  hypodermic  injections,  which  through  perspiration 
and  salivation  eliminates  the  lead.  In  this  way  the  crisis  is  shortened  and 
the  pressure  on  the  kidneys,  which  ordinarily  in  cases  of  saturnine  colic  go 
through  a  light  phase  of  acute  nephritis,  is  avoided. 

It  is  the  experience  of  the  Chnic  that  many  workmen,  in  whom  lead  poi- 
soning is  taking  effect,  present  three  orders  of  disturbances,  viz. :  paleness, 
dyspepsia  and  weakness.  Our  advice  to  them  is  to  stop  work  for  some  days 
and  observe  a  scrupulous  cleanliness.  After  10  days  a  remarkable  improve- 
ment is  noted,  due  to  the  elimination  of  lead  which  is  not  replaced.  Another 
result  of  the  investigations  made  is  that  persons  over  50  years  of  age  should 
not  engage  in  occupations  of  any  kind  where  there  is  a  possibility  of  saturn- 
ism, because  they  become  more  easily  affected  by  it,  and  in  very  serious 
forms  (as  nephritis,  arteriosclerosis,  paralysis,  glandular  insufl&ciency). 

Children  of  persons  affected  by  saturnism  should  never  attempt  to  work 
in  trades  which  would  put  them  in  contact  with  lead. 

Our  consultation  statistics  show  that  8040  working  people  have  been 
examined  in  3  years  and  11  months. 

5.  mSPECTIONS  AND  INVESTIGATIONS 

The  activity  of  our  consultation  service  extends  also  to  examinations  of 
working  people  in  their  homes  and  to  investigations  concerning  certain  trades, 
on  request  of  the  manufacturers,  the  State,  or  the  workmen  themseh'es.  I 
point  out  as  an  example  worthy  of  praise  the  case  of  the  Milanese  varnishers 
who,  every  2  weeks,  undergo  an  examination  in  their  meeting  place,  and  that 
of  the  printers  who  also  submit  themselves  regularly  to  the  professional  visit 
of  the  professors  or  assistants  attached  to  the  Clinic.     A  fact  worth  men- 


774  THE   PREVENTION   OF    OCCUPATIONAL   DISEASES 

tioning  occurred  in  connection  with  the  strike  of  the  lead  capsule  and  label 
makers,  when  the  Chnic  demonstrated  that  a  large  percentage  of  the  strikers 
were  affected  by  saturnism,  thus  inducing  the  manufacturers  to  make  them 
better  propositions  as  to  wages,  etc. 

During  the  few  years  of  existence  of  the  Clinic,  the  following  researches 
have  been  conducted  by  Dr.  Carozzi,  Chief  of  the  Investigation  Department: 

"Hygienic-sanitary  conditions  of  the  silk  industry." 
"Investigation  of  the  polygraphic  industry  in  Italy." 
"Contribution  to  the  so-called  anaemia  of  the  photographers." 
"Hygienic  protection  of  workmen  engaged  in  graphic  arts." 
"Factory  work  taken  home  and  its  relation  to  tuberculosis." 
"Infant  mortality  in  relation  with  parents'  occupation." 
A  very  remarkable  investigation  is  the  one  conducted  by  Dr.  Peri  on  the 
"Professional  Pathology  of  Dramatic  Artists." 

6.  POPULAR  PROPAGANDA  ON  OCCUPATIONAL  HYGIENE 

I  am  very  glad,  indeed,  to  have  opened  the  Clinic  (which  was  formerly 
intended  only  for  physicians)  to  the  public  in  general,  and  especially  to  the 
working  class.  At  first  we  used  to  give  general  lectures  on  the  various 
occupational  diseases,  but  now  we  prefer  to  speak  about  each  trade  and  pro- 
fession, because  in  this  way  the  attention  of  the  workmen  is  more  easily 
attracted  and  their  interest  won  far  more  readily;  so  we  try  in  every  lecture 
to  illustrate  very  plainly  the  pathology  and  hygiene  that  varnishers,  decora- 
tors, printers,  t^'pists,  glove  makers,  nurses,  type  founders,  etc.,  should  know, 
and  for  this  we  draw  upon  the  experience  and  material  accumulated  by  the 
Clinic,  which  affords  illustrations  of  actual  cases  of  the  life  and  labor  environ- 
ment of  the  people.  It  is  convincing  to  them  to  show  what  a  powerful  foe 
to  the  health  and  hygiene  of  workers  alcohol  is,  by  exhibiting  at  our  popular 
lectures  the  bowels  and  other  internal  organs  of  hard-drinking  workmen  who, 
before  dying,  donated  their  bodies  to  the  anatomic  collection  of  the  Clinic. 

The  Museum  of  Labor  Hygiene  and  Pathology  possesses  many  specimens 
(as  shown  in  the  hygienic  exhibition  of  Dresden),  tables,  drawings,  anatomic 
pieces  and  photographs  illustrating  unwholesome  labor  environments, 
pathological  cases,  etc.,  and  these  have  been  drawn  upon  to  great  advantage 
in  our  popular  propaganda.  This  Museum,  which  is  new,  is  open  to  the  public 
on  holidays  from  lo  to  12  A.M.,  and  I  hope  that  in  the  future  it  will  have 
sections  for  general  phenomena  as  strain,  fatigue,  alimentation,  alcohol,  dusts, 
and  others  dedicated  to  the  various  categories  of  the  trades  of  Milan  and 
its  suburbs,  so  that  proprietors,  manufacturers,  and  employees  may  find 
in  each  single  section  all  that  physiology,  pathology,  hygiene,  statistics  and 
social  assistance  have  to  offer  in  their  respective  trades,  occupations  and 
industries.     I  believe  that,  by  acting  chiefly  upon  employers  and  workmen, 


MILAN   CLINIC   FOR   OCCUPATIONAL   DISEASES  775 

we  can  more  easily  attain  the  purpose  of  eliminating  from  the  trades  all  that 
is  dangerous  to  the  body  and  sometimes  to  the  spirit  of  the  laborer. 

The  expenses  of  the  Clinic  (teaching,  laboratories,  out-patients  and  assist- 
ance to  45  patients)  requires  a  yearly  output  of  100,000  lire;  the  annual 
balance  shows  a  deficit  of  20,000  lire,  which  is  covered  by  contributions. 

Summing  it  all  up  in  a  sentence,  the  Clinic  of  Milan,  by  its  work  and 
propaganda,  is  a  daily  illustration  by  work  and  deed  of  the  wisdom  contained 
in  Ramazzini's  motto:  ^^ Medici  munus  plebeios  ciirantis  est  interrogare  qiias 
artes  exerceant;"  teaching  to  physicians  the  technic  of  specific  exploration, 
of  diagnosis  and  of  prevention,  as  well  as  that  of  treatment,  it  aims  at  edu- 
cating them  to  detect  accurately  in  the  infirmities  of  working  people  what  to- 
day is  to  be  traced  back  to  trades,  and  to  avoid  in  the  future — if  not  totally, 
at  least  in  a  great  proportion — the  evil  consequences  of  such  unwholesome 
trades;  and  it  works  for  the  extension  of  education  and  of  class  collaboration, 
availing  itself  of  the  cooperation  of  willing  workmen  and  of  all  who  are 
prompted,  by  noble  feelings,  to  take  an  interest  in  the  hygiene  of  work. 

In  fact  the  workmen  of  Milan  love  the  Clinic  and  from  time  to  time  give 
it  financial  support,  showing  how  they  trust  and  respect  it,  because,  being 
under  no  political  influence,  it  has  only  one  rule:  the  attainment  of  whatever 
truth  mortals  can  reach,  and  only  one  method:  to  observe  and  to  experiment. 

Will  other  Clinics  like  this  be  established?  I  hope  so,  yet  I  cannot  but 
see  the  difficulties  that  may  arise.  Milan  enjoyed  especially  favorable  con- 
ditions when  the  Clinic  was  decided  upon;  the  historical  period  1901-1902 
was  particularly  appropriate  to  give  it  impetus,  and  the  lack  of  a  Faculty 
of  medicine  in  the  city  greatly  facilitated  the  task  because,  generally,  Facul- 
ties either  are  too  busy  with  the  branches  of  teaching  already  existing  (which 
are  themselves  not  well  equipped)  or  are  misoneistic;  moreover,  the  opening 
of  a  Labor  Clinic  does  not,  at  first  sight,  gain  favor,  as  it  looks  rather  like  a 
revolutionary  institution,  when  compared  with  the  old  academic  grouping  of 
the  clinical  world.  It  concerns  itself  with  the  organs  of  the  altered  functions 
rather  than  with  the  causing  agent.  As  there  already  exist  courses  of  teach- 
ing named  after  the  cause  of  disease  (syphilology,  bacteriology,  clinical 
parasitology)  or  after  the  regions  of  origin  .of  some  sicknesses  (tropical  dis- 
eases), and  that  in  other  fields,  as  for  instance  in  commerce,  there  are  already 
schools  of  every  kind,  should  labor,  which  is  one  of  the  greatest  factors  of  life 
and  which  in  fact  ought  to  be  studied  from  all  its  angles  so  as  to  be  made  a 
wholesome  cause  of  happiness,  remain  without  its  own  medical  hygienic 
institutions? 

But,  I  repeat,  a  Clinic  for  the  pathology  of  work  cannot  be  a  mere  in- 
firmary for  persons  affected  by  saturnism  or  mercurialism  and  other  common 
forms  of  occupational  diseases;  it  must  be  a  vast  and  complex  institution, 
able  to  cope  with  the  majority  of  biological,  clinical  and  hygienic  problems 
arising  from  work,  and  aim  to  be  able  to  provide  for  ample  means  of  study 
of  good  clinical  material,  by  a  complete  staff.     I  hope  that  in  due  time  this 


776  THE    PREVENTION    OF    OCCUPATIONAL    DISEASES 

Clinic  of  Milan,  the  first  established,  may  become,  little  by  little,  the  social 
medico-hygienic  labor  faculty,  a  mixed  international  school  open  to  every 
one,  physician  or  not,  to  ill  or  healthy  persons,  to  all  who  are  willing  to  con- 
tribute toward  the  realization  of  healthier  and  more  physiological  occupa- 
tions, which  is  the  dream  of  all  who  are  kindly  hearted. 

On  the  corner-stone  of  the  Clinic  of  Milan  this  is  carved:  in  aliis  vivimus, 
movemur  et  sumiis. 

STATISTICS 

The  patients  received  in  the  Clinic  number  to  iioo,  affected  as  follows: 

Saturnism  (of  which  46  are  affected  by  chronic  nephritis) 343 

Other  professional  intoxications 20 

Tubercular  affections  of  the  bronchia  and  of  the  lungs 112 

Tuberculosis 23 

Tuberculosis  with  pneumokoniosis 12 

Miners'  phthisis 8 

Pellagra 81 

Heart  diseases 80 

Aortitis,  arteritis,  and  phlebitis 47 

Aneurism 6 

Renal  ectopy  and  other  affections  of  the  urinary  organs 88 

Blood  and  miscellaneous  diseases 144 

Joint  and  muscle  affections 21 

Nervous  system  disturbances 67 

Basedow's  disease  and  other  similar  forms 12 

Ankylostomiasis 12 

Caissonism 7 

Bone  affections 7 

Skin  affections 7 

Stomach,  intestines,  liver,  spleen,  spine  affections  (spondylosis) 3 

REFERENCES 

Devoto,  L. — The  Clinic  for  Occupational  Diseases  of  the  Royal  Clinical  Institute  of  Milan. 
Enrico  Reggiani,  Milano,  1913.  La  Clinica  per  le  malattie  del  Lavoro  dei  R.  R. 
Istituti  Clinici  di  perfezionanento  di  Milano.     Tip.  Enrico  Reggiani,  Milano,  1913. 


DIVISION  n 


Statistical  Studies  Relating  to  Occupational  Diseases 
CHAPTER  I 

MORTALITY    FROM    PULMONARY    TUBERCULOSIS    IN    DUSTY 

OCCUPATIONS 

BY  FREDERICK  L.  HOFFMAX.  LL.  D.,  Newark,  N.  J. 

Of  the  44,130,000  American  wage  earners  of  both  sexes,  as  estimated  for 
the  year  1915,  probably  at  least  5,600,000,  or  12.7  per  cent.,  work  under 
conditions  more  or  less  detrimental  to  health  and  life  on  account  of  atmos- 
pheric pollution,  or  the  relatively  excessive  presence  of  atmospheric  impuri- 
ties predisposing  to,  or  accelerating,  the  relative  frequency  of  tubercular  and 
respiratory  diseases.  The  vast  army  of  men  and  women  exposed  to  the  risk 
of  ill-health  in  industry  on  account  of  atmospheric  impurities  caused  by  dust, 
fumes,  or  gas  approximately  divides  itself  as  follows: 

Number  of  Persons  Engaged  tn  Occupations  More  or  Less  Exposing  to  Injurious 
Dusts,  Gases  or  Fumes,  xn  the  United  States,  1915  (i\GES  10  Years  ant) 

Over)  * 


Exposure  to 


Males 


Females 


Persons 


Metallic  dust 847,689 

Mineral  dust '.  .  .  !    756,459 

Vegetable  fiber  dust I    152,999 

638,997 
500,936 
702,251 


Animal  and  mixed  fiber  dust. 

General  organic  dust 

Municipal  dust 


Gas  exposure,  fumes,  etc 1,196,191 


45.387 

16,424 

22,467 

494,505 

214,23s 

180 

19,954 


893,076 
772,883 
175,466 

1,133,502 
715,171 
702,431 

1,216,14s 


Total 4,795,522  ;  813,152    5,608,674 

The  present  discussion  is  limited  to  the  so-called  dusty  trades.  To  a  not 
inconsiderable  extent,  however,  other  atmospheric  impurities,  such  as  gases 
and  fumes,  are  also  injurious  to  heatlh  and  longevity,  but  the  effects  on  the 
organism  are  not  such  as  to  result  in  a  material  increase  in  disease  liabiUty 
to  tubercular  and  respiratory  diseases.  Dust  is  a  convenient  term,  which 
includes  a  multitude  of  widely  varying  sources  of  visible  and  determinable 
atmospheric  impurities.  Dust  is  anywhere  and  everywhere,  but  the  propor- 
tion of  injurious  particles  in  the  air,  as  ascertained,  for  illustration,  in  city  or 
municipal  dust,  or  in  the  air  of  schoolhouses,  places  of  worship,  etc.,  is  rela- 
tively low,  due,  of  course,  to  the  rapid  dispersion  of  the  minute  particles  in  an 
*  Estimate  based  upon  the  U.  S.  census  of  1910  and  the  rate  of  increase,  1900-1910,  of  all 
occupied  males  and  all  occupied  females. 

777 


778  STUDIES   RELATING   TO    OCCUPATIONAL   DISEASES 

area  of  unlimited  extent.  Streets  and  roads  frequently  suffer  serious  dust 
pollution,  and  much  more  at  present  on  account  of  the  introduction  of  me- 
chanically propelled  vehicles,  which  are  rapidly  taking  the  place  of  vehicles 
drawn  by  animals.  Even  in  the  best  kept  homes  a  certain  amount  of  atmos- 
pheric dust  pollution  is  inevitable,  and  in  the  absence  of  effective  methods  of 
ventilation  the  relative  amount  of  impurities  may  attain  to  serious  pro- 
portions; especially  is  this  true  of  hbraries,  where  dust  accumulates  on  book- 
shelves and  where  the  books  themselves  may  be  carriers  of  pathogenic  bacteria. 
It  is  necessary  to  keep  these  facts  in  mind  in  considering  the  larger  problem  of 
industrial  dust,  since  the  health-injurious  consequences  are  not  entirely  trace- 
able, or  attributable  to  the  latter,  but  in  a  measurable  number  of  cases  the 
real  harm  to  the  respiratory  organs  may  have  resulted  from  atmospheric 
impurities  out  of  doors,  in  the  home,  or  in  public  places  of  entertainment, 
worship,  and  instruction. 

I.  Definitions  of  Industrial  Dusts 

It  is  in  industries  that  the  dust  problem  assumes  the  greatest  practical 
importance,  and  three  distinct  classes  of  dust  have  been  described  and  pre- 
cisely differentiated  by  Charles  Baskerville,  Ph.  D.,  in  a  dissertation  on  "Air 
Impurities:  Dusts,  Fumes,  and  Gases,"  in  the  New  York  Medical  Journal 
for  November  23  and  30,  191 2. 

First,  as  regards  insoluble  inorganic  dusts,  it  is  said  that  "  this  class  includes 
metals  (antimony,  arsenic,  type  metal,  brass,  bronze,  copper,  aluminum,  iron, 
steel,  lead,  manganese,  vanadium  and  ferrovanadium,  silver,  tin,  zinc,  and 
solder)  in  a  state  of  fine  division  (dusts,  atomized  metals,  metallic  powders) ; 
flue  dusts;  various  ore  dusts  (iron  ore,  etc.);  sihca,  sand,  emery,  flint,  glass 
powders;  carbon  graphite,  diamond,  coal,  soot;  brick  dust,  marble,  granite, 
cement,  terra  cotta;  lime,  gypsum,  plaster,  meerschaum;  phosphates,  guano, 
etc."  The  continuous  and  considerable  exposure  to  the  inhalation  of  insolu- 
ble inorganic  dusts,  according  to  Baskerville  (who  is  sustained  by  numerous 
other  authorities)  may  result  in  fibrosis  of  the  lungs,  chiefly  because  of  the 
inhalation  of  siliceous  or  metallic  particles,  as,  for  example,  is  the  case  in  the 
so-called  potter's  asthma  and  grinder's  phthisis.  Pneumonia  has  been 
reported  as  frequent  among  workmen  in  blast  furnaces,  owing  in  part,  di- 
rectly or  indirectly,  to  the  inhalation  of  slag  dust.  The  disease  known  as 
siderosis  is  commonly  met  with  among  metal  polishers,  knife  grinders,  and 
others  engaged  in  metal  working. 

Second,  Soluble  Inorganic  Dusts.—This  class,  according  to  Baskerville, 
includes  such  substances  as  are  likely  to  be  swallowed  and  absorbed,  as,  for 
illustration,  metal  particles,  including  lead,  brass,  copper,  zinc,  arsenic,  mer- 
cury, and  silver,  as  well  as  soluble  inorganic  salts.  Many  dusts  of  this  class, 
it  is  pointed  out,  "are  dangerous  not  only  because  of  their  irritating  or  poi- 
sonous properties,  but  also  because  of  their  inflammability,  e.g.,  potassium 
chlorate." 


PULMONARY   TUBERCULOSIS    IN   DUSTY    OCCUPATIONS  779 

Third,  Organic  Dusts. — This  class  is  defined  as  comprising  such  widely 
varying  materials  as  "sawdust,  fur,  skins,  feathers,  broom  and  straw,  grains 
and  flours,  jute,  flax,  hemp,  cotton,  wool,  carpet  dust,  street  sweepings,  to- 
bacco-box dust,  hides  and  leather,  felts,  rags,  paper,  horsehair,  etc."  Typical 
of  the  diseases  caused  by  organic  dusts  are:  flax  dressers'  disease,  a  kind  of 
pneumonia  due  to  the  inhalation  of  particles  of  flax;  alkaloidal  poisoning 
from  African  boxwood  by  workmen  engaged  in  shuttle  making;  and  malig- 
nant pustule  and  a  febrile  disease  among  rag  sorters." 

II.  Air  Analysis 

This  formidable  array  of  health-injurious  conditions  arising  out  of  dust 
which,  by  its  mechanical  properties,  results  (i)  in  a  chronic  irritation  of  the 
respiratory  and  pulmonary  organs  and  (2)  by  the  lesions  caused,  predisposes 
to  tuberculosis,  frequently  with  disastrous  results,  suggests  the  exceptional 
practical  importance  of  extended  and  thoroughly  qualified  consideration  of 
every  aspect  of  the  question  under  discussion. 

The  amount  of  mischief  done,  however,  is  not  limited  to  the  mechanical 
and  chemical  properties  of  industrial  dust,  but  additional  thereto  the  microbic 
contents  of  the  air  require  to  be  taken  into  account.  This  aspect  of  the  in- 
dustrial disease  problem  has  been  considered  with  admirable  thoroughness  by 
Winslow  and  Browne,  in  behalf  of  the  New  York  State  Commission  on  Venti- 
lation. These  authors,  in  a  contribution  to  the  ^Monthly  Weather  Review 
for  July,  1914,  provide  a  table  showing  the  percentages  of  microbes  per  cubic 
foot  of  air  in  samples  from  various  sources,  as  shown  in  the  table  below: 

Microbes  in'  Am  from  Various  Sources 

(Gelatin,  2o°C.) 

(Percentage  of  samples  in  each  case) 

"'"Ter'cJbi^^oof^'  Country  Offices  City  Schools        j        Factories 

0-25  44 

26-50  25 

51-75  II 

76-100  7 

101-125  7 

126-150  3 

151-175   : 

1 76-200    ! 

201-225 
226-250 

251-275 
276-300 

301-325 
326-350 

351-375 

376-400 

Over  400 


42 

28 

24 

1     12 

23 

24 

17 

IS 

9 

16 

14 

20 

2 

6 

13 

6 

4 

8 

10 

29 

2 

4 

7 

3 

3 

4 

4 

I 

2 

6 

2 

122 
3          I 

i 

I     I 

3 

i 

I 

3 

I    1 

3 

I          I     

4          2          2 

3 

780  STUDIES   RELATING   TO    OCCUPATIONAL   DISEASES 

The  extremely  interesting  and  suggestive  fact  is  disclosed  by  this  table 
that  the  country  air  is  evidently  much  freer  from  microbic  life  than  that  of  the 
city  streets,  and  that  the  factory  air  has  clearly  the  largest  amount  of  microbic 
contents  as  determined  by  this  method. 

Air  analysis  is  a  difficult  and  always  highly  technical  procedure.  As  yet 
few  qualified  investigations  have  been  made  to  determine  with  approximate 
accuracy  the  actual  atmospheric  conditions  in  a  large  number  of  industrial 
plants  under  varying  weather  conditions  and  as  modified  by  widely  divergent 
methods  of  ventilation  and  dust  control.  It  has  properly  been  pointed  out 
at  the  outset  that  ordinary  air  itself  is  more  or  less  polluted,  but  the  outside 
atmosphere  is  practically  free  from  the  common  impurities  of  the  air  in 
industrial  establishments,  surcharged  with  minute  particles  of  inorganic  or 
organic  matter  which,  under  given  conditions,  may,  in  fact  (as,  for  illustra- 
tion, in  cement  or  wheat  flour),  constitute  the  object  of  the  industry  itself. 
In  this  connection  the  following  very  interesting  observations  on  air  pollution 
may  be  quoted  from  "A  Study  of  the  Hygienic  Condition  of  the  Air  in  Textile 
Mills  with  Reference  to  the  Influence  of  Artificial  Humidification,"  in  the 
Monthly  Bulletin  of  the  Massachusetts  Board  of  Health  for  July,  1913: 

"Ordinary  ;ur  always  contains  a  greater  or  less  amount  of  both  dead  and  living  matters 
in  suspension  which  may  have  an  important  influence  upon  the  health.  The  dead  matter  or 
dust,  consisting  of  particles  of  mineral  matter  from  the  streets  and  pavements  and  from 
vehicles  and  machinery,  and  of  dead  organic  matter  from  the  floors  and  walls,  from  cloth- 
ing and  from  the  emanations  of  men  and  animals,  especially  when  present  in  excessive 
amounts,  irritates  the  mucous  membrane  of  the  lungs  and  respiratory  passages  and  renders 
them  more  susceptible  to  invasion  by  the  germs  of  disease.  The  living  matter  consists  of 
bacteria,  yeasts  and  moulds  which  are  always  present  in  greater  or  less  numbers,  and  which 
have  found  their  way  into  the  air  attached  to  dust  particles,  or  have  been  projected  directly 
into  the  air  from  the  body  by  the  acts  of  coughing  and  sneezing.  So  far  as  is  known  the 
yeasts  and  moulds  have  little  pathological  significance,  but  it  is  well  recognized  that  the 
germs  of  tuberculosis,  pneumonia,  influenza  and  perhaps  other  diseases  are  frequently 
transmitted  through  the  air." 

The  general  conditions  of  atmospheric  pollution  simply  tend  to  exagger- 
ate or  increase  the  observed  injurious  consequences  of  continuous  and  con- 
siderable exposure  to  industrial  dust. 

III.  Occupation  Mortality  Statistics 

The  aggregate  mortality  from  tuberculosis  in  the  continental  United 
States  for  the  year  19 15  may  be  conservatively  estimated  at  150,000,  of  which 
about  130,000  are  deaths  from  pulmonary  tuberculosis,  and  about  20,000, 
from  other  forms  of  tuberculosis,  chiefly  acute  miHary  tuberculosis,  tubercu- 
lous meningitis,  and  abdominal  tuberculosis.  The  tuberculosis  death  rate  of 
the  registration  area  for  the  year  1913  was  147.6  per  100,000  of  population, 
which  contrasts  with  a  rate  of  201,9  for  the  year  1900.  The  decline  in  tuber- 
culosis is  one  of  the  most  gratifying  evidences  of  modern  sanitary  and  public 


PULMONARY    TI.-BERCULOSIS    IN    DUSTY    OCCUPATIONS  78 1 

health  progress,  and  while  attributable  to  a  large  variety  of  important  causes 
and  altered  social  and  economic  conditions,  it  is  probably  safe  to  assume  that  a 
not  inconsiderable  share  in  this  reduction  of  the  death  rate  is  to  be  assigned  to 
the  very  material  improvement  in  the  conditions  or  methods  of  factory  life  and 
the  higher  regard  paid  to  the  physical  health  and  comfort  of  the  employees. 
As  a  general  introduction  to  the  scientific  study  of  the  problem  of  tuberculosis 
in  industry,  it  is  essential  to  take  note  of  the  wide  disparity  in  the  relative 
death  rates  by  age  and  sex.  The  table  following  shows  the  rates  as  determined 
for  the  United  States  registration  area  for  the  period  1909-13.  The  rates  are 
limited  to  pulmonary  tuberculosis,  and  include  an  aggregate  of  nearly  400,000 
deaths  of  both  sexes  during  the  five  years  under  observation: 

Comparative  ^Mortality  from  Pulmonary  Tl'berci:losis 
U.  S.  Registration  Area,  1909-1913 
(Rate  per  100,000  of  population) 

Ages  Males  Females 

I I 

I 
Under  5  years 

5-14  years 

15-44  years 

45-64  years 

65  and  over 

.\11  ages I       145.  2  116.  2 

This  table  is  of  exceptional  interest  and  importance.  It  is  shown  that  at 
ages  under  5  years  the  rates  are  about  the  same  for  both  sexes,  but  at  ages 
5-14  the  female  rate  is  nearly  twice  the  male  rate.  During  the  age  period 
15-44  the  male  rate  but  slightly  exceeds  the  female  rate,  but  nearly  twice 
the  relative  mortality  from  pulmonary  tuberculosis  occurs  among  men 
at  ages  45-64,  when  compared  with  the  corresponding  death  rate  for  women. 
At  ages  65  and  over  the  rates  approach  each  other,  but  there  remains  a  con- 
siderable excess  in  the  relative  mortality  of  males.  Combining  all  ages,  the 
excess  in  the  male  rate  is  29.0  per  100,000  of  population,  but  the  excess  at 
ages  45-64  is  106.9,  or  equivalent  to  i  per  1000.  There  is  no  escape  from  the 
conclusion  that  under  the  known  conditions  of  industrial  life,  and  the  relative 
age  distribution  of  wage  earners  of  both  sexes,  this  exceis  in  the  mortality 
from  tuberculosis  among  men  of  ages  45-64  is  largely,  if  not  exclusively,  the 
result  of  health-injurious  conditions  in  industry,  enhanced,  no  doubt,  more 
or  less  by  habits  and  a  more  general  indifference  to  the  requirements  of 
personal  hygiene. 

The  differences  in  the  mortality  from  pulmonary  tuberculosis  by  no  means 
measure  the  full  extent  of  the  higher  mortality  among  adult  males,  due  more  or 
less  to  the  strain  and  stress  of  industrial  life.  The  mortality  from  respiratory 
diseases  is  also  higher  among  men,  and  especially  from  lobar  pneumonia. 


33-7 

29.7 

10.8 

20.6 

;     184.6 

165.5 

227.0 

\        120. I 

195-3 

148.9 

782  STUDIES   RELATING   TO    OCCUPATIONAL   DISEASES 

For  all  respiratory  diseases  combined  the  male  death  rate  in  the  registration 
area  during  1908-12  was  185.0  per  100,000,  in  comparison  with  a  rate  of 
163.7  among  women.  Since  it  is  frequently  asserted  that,  in  a  large  measure, 
the  higher  death  rate  of  males  from  pulmonary  tuberculosis  in  adult  life  is 
the  result  of  health-injurious  habits,  rather  than  health-injurious  occupations 
or  industrial  conditions,  it  is  significant  that  the  differences  in  the  mortality 
from  lobar  pneumonia,  which  is  a  much  better  indication,  should  be  so  much 
less  than  in  pulmonary  tuberculosis. 

IV.  Relative  Incidence  of  Tuberculosis  in  Dusty  Trades 

Proceeding  from  these  general  considerations  to  the  special  problem  of  the 
mortality  from  tuberculosis  in  dusty  trades,  it  has  seemed  best  to  present  the 
results  in  a  series  of  tables,  which  are  the  underlying  data  of  a  series  of  c  harts 
furnished  to  the  U.  S.  Bureau  of  Labor  Statistics  as  part  of  a  collective  exhibit 
prepared  for  the  Panama-Pacific  International  Exposition.  The  tables  are 
derived  exclusively  from  the  industrial  mortality  experience  of  the  Prudential, 
and  while  limited  to  the  proportionate  method,  they  conform,  in  the  main,  to 
similar  results  arrived  at  by  means  of  rates  calculated  in  accordance  with  more 
precise  and  satisfactory  methods  of  statistical  inquiry.  It,  unfortunately,  is 
not  possible  to  correlate  the  deaths  by  occupations  in  the  Company's  indus- 
trial experience  to  the  exposed  to  risk.  For  the  purposes  of  industrial  hy- 
giene, however,  the  proportionate  method  is  quite  satisfactory,  and  perhaps 
even  more  so  when  the  fact  is  considered  that  by  this  means  the  exact  quanti- 
tative amount  of  mortality  from  a  specified  group  of  diseases  is  shown  in  its 
relation  to  groups  of  occupations  or  particular  employments.  On  the  basis 
of  the  Company's  experience  for  1907-1912,  including  162,765  deaths  of 
occupied  males,  the  proportion  of  deaths  from  tuberculosis  of  the  lungs  at 
ages  15-24  was  34.2  per  cent,  of  the  mortality  from  all  causes  in  this  group; 
at  ages  25-44  it  was  37.4  per  cent.;  at  ages  45-64  it  was  13.5  per  cent. ;  and  at 
ages  65  and  over  it  was  3.1  per  cent.  Relatively  as  well  as  actually,  therefore, 
tuberculosis  of  the  lungs  was  of  most  importance  at  ages  25-44,  which,  broadly 
speaking,  coincides  with  the  period  of  greatest  productive  eflaciency  on  the 
part  of  wage  earners  collectively  considered. 

The  experience  has  been  arranged  according  to  the  character  of  the  dust, 
in  six  groups,  as  follows: 

I.  Metallic  dust,  including  3,374  deaths  from  all  causes,  and  1,208  deaths 
from  tuberculosis. 

3.  Mineral  dust,  including  3,734  deaths  from  all  causes,  and  1,037  deaths 
from  tuberculosis. 

3.  Vegetable  fiber  dust,  including  1,120  deaths  from  all  causes,  and  344 
deaths  from  tuberculosis. 

4.  Animal  and  mixed  fiber  dust,  including  1,276  deaths  from  all  causes, 
and  372  deaths  from  tuberculosis. 


PULMONARY   TUBERCULOSIS    IN   DUSTY    OCCUPATIONS  783 

5.  General  organic  dust,  including  5,694  deaths  from  all  causes,  and  1,140 
deaths  from  tuberculosis. 

6.  Municipal  dust,  including  10,567  deaths  from  all  causes,  and,  3,021 
deaths  from  tuberculosis. 

In  the  group  considered  chiefly  with  reference  to  exposure  to  metallic  dust, 
16  specific  occupations  are  given.  At  ages  15-24  the  proportionate  mortality 
from  tuberculosis  of  the  lungs  was  45.2  per  cent.;  at  ages  25-44  it  was  49.7 
per  cent.;  at  ages  45-64  it  was  21.1  per  cent.;  and  at  ages  65  and  over  it  was 
5.4  per  cent.  The  corresponding  proportionate  mortality  from  respiratory 
diseases  in  this  group  at  ages  15-24  was  7.0  per  cent.;  at  ages  25-44  it  was 
8.9  per  cent. ;  at  ages  45-64  it  was  13.6  per  cent. ;  and  at  ages  65  and  over  it  was 
14.8  per  cent. 

In  the  group  considered  chiefly  with  reference  to  exposure  to  mineral  dust, 
13  specific  occupations  are  given.  At  ages  15-24  the  proportionate  mortality 
from  tuberculosis  of  the  lungs  was  33.1  per  cent.;  at  ages  25-44  it  was  41.  i  per 
cent.;  at  ages  45-64  it  was  22.7  per  cent.;  and  at  ages  65  and  over  it  was  7.0 
per  cent.  The  corresponding  proportionate  mortality  from  respiratory 
diseases  in  this  group  at  ages  15-24  was  13.6  per  cent.;  at  ages  25-44  it  was 
1 1.5  per  cent.;  at  ages  45-64  it  was  14.9  per  cent.;  and  at  ages  65  and  over  it 
was  16.1  per  cent. 

In  the  group  considered  chiefly  with  reference  to  exposure  to  vegetable 
fiber  dust,  12  specific  occupations  are  given.  At  ages  15-24  the  proportionate 
mortality  from  tuberculosis  of  the  lungs  was  41.2  per  cent. ;  at  ages  25-44  it  was 
49.5  per  cent.;  at  ages  45-64  it  was  21.3  per  cent.;  and  at  ages  65  and  over  it 
was  4.6  per  cent.  The  corresponding  proportipnate  mortality  from  respira- 
tory diseases  in  this  group  at  ages  15-24  was  10.8  per  cent.;  at  ages  25-44  it 
was  6.3  per  cent.;  at  ages  45-64  it  was  13.7  per  cent.;  and  at  ages  65  and  over 
it  was  13.9  per  cent. 

In  the  group  considered  chiefly  with  reference  to  exposure  to  animal  and 
mixed  fiber  dust,  8  specific  occupations  are  given.  At  ages  15-24  the  pro- 
portionate mortality  from  tuberculosis  of  the  lungs  was  46.3  per  cent.;  at  ages 
25-44  it  was  49.7  per  cent.;  at  ages  45-64  it  was  17.5  per  cent.;  and  at  ages  65 
and  over  it  was  3.1  per  cent.  The  corresponding  proportionate  mortality 
from  respiratory  diseases  in  this  group  at  ages  15-24  was  9.9  per  cent.;  at  ages 
25-44  it  was  10. 1  per  cent.;  at  ages  45-64  it  was  11.6  per  cent.;  and  at  ages 
65  and  over  it  was  12.9  per  cent. 

In  the  group  considered  chiefly  with  reference  to  exposure  to  general 
organic  dust,  15  specific  occupations  are  given.  At  ages  15-24  the  propor- 
tionate mortality  from  tubercidosis  of  the  lungs  was  38.6  per  cent.;  at  ages 
25-44  it  was  43.1  per  cent. ;  at  ages  45-64  it  was  14.6  per  cent. ;  and  at  ages  65 
and  over  it  was  3.5  per  cent.  The  corresponding  proportionate  mortality 
from  respiratory  diseases  in  this  group  at  ages  15-24  was  7.6  per  cent. ;  at  ages 
25-44  it  was  10.7  per  cent.;  at  ages  45-64  it  was  12.8  per  cent.;  and  at  ages  65 
and  over  it  was  14.  i  per  cent. 


784  STUDIES    RELATING    TO    OCCUPATIONAL    DISEASES 

In  the  group  considered  chiefly  with  reference  to  exposure  to  municipal 
dust,  six  specific  occupations  are  given.  At  ages  15-24  the  proportionate 
mortahty  from  tuberculosis  of  the  lungs  was  36.1  per  cent. ;  at  ages  25-44  it  was 
39.7  per  cent.;  at  ages  45-64  it  was  16.2  per  cent.;  and  at  ages  65  and  over  it 
was  3.1  per  cent.  The  corresponding  proportionate  mortality  from  respira- 
tory diseases  in  this  group  at  ages  15-24  was  8.2  per  cent. ;  at  ages  25-44  it  was 
10.4  per  cent.;  at  ages  45-64  it  was  13.3  per  cent.;  and  at  65  and  over  it  was 
15.3  per  cent. 

V.  Miners'  Phthisis 

More  intensive  statistical  investigations  yield  results  of  even  greater  prac- 
tical value.  As  yet,  however,  not  many  industries  and  specific  occupations 
have  been  made  the  subject  of  extended  specialized  statistical  and  medical 
consideration.  Any  single  disease  factor  is  bound  to  become  obscured  where 
a  number  of  other  determining  circumstances  modify  the  results.  Age,  sex, 
race,  and  even  climate  require  to  be  taken  into  account.  Miners'  phthisis 
is  an  excellent  illustration  of  an  industrial  disease  common  to  an  industry 
only  under  exceptional  conditions.  Modern  rock  drilling,  particularly  in 
siliceous  rock,  is  an  exceptionally  dusty  operation,  followed  invariably,  unless 
subject  to  control,  by  extensive  injuries  to  the  health  of  persons  employed 
underground.  Among  coal  miners  tuberculosis  is  very  rare.  Among  metal 
miners  working  in  quartz  rock  the  disease  is  very  common.  In  Montana, 
regardless  of  a  high  proportionate  mortality  from  accidents,  the  percentage 
of  deaths  from  tuberculosis  was  10.8  at  ages  15-24,  28.5  at  ages  25-44,  35.0 
at  ages  45-64,  and  9.7  at  ages  65  and  over.  These  interesting  statistics  are 
based  upon  an  original  examination  of  the  mortality  records  of  Butte,  Mont., 
for  1907-1911.  Conditions  are  even  worse  in  the  Joplin  zinc-and-lead  mining 
district  of  Missouri.  As  the  result  of  official  investigations  it  has  been  shown 
that  the  prevalence  of  tuberculosis  and  fibrosis  in  southwestern  Missouri  is 
closely  related  to  excessive  dust  in  sheet-ground  mines.  As  shown  by  a 
report  made  by  A.  J.  Lanza,  M.  D.,  of  the  U.  S.  Public  Health  Service,  and 
Mr.  Edwin  Higgins,  mining  engineer  of  the  U.  S.  Bureau  of  Mines,  the  dust 
is  caused  by  various  practices  but  chiefly  by  the  blowing  of  dry  holes.  The 
recommendations  offered  as  the  result  of  this  investigation  are  of  such  ex- 
ceptional practical  importance  that  they  may  safely  be  considered  as  a  first 
requirement  for  the  effective  sanitary  control  of  health-injurious  conditions 
in  the  practice  of  metal  mining  in  general. 

I.  Means  should  be  employed  for  the  abatement  of  rock  dust  in  the  mines 
as  follows:  Provide  a  water  supply  for  every  working  face,  preferably  by  the 
laying  of  separate  water  fines;  as  rapidly  as  may  be,  without  too  great  cost, 
equip  all  miners  with  some  type  of  drilling  machine  which  provides  for  water 
passing  through  the  core  of  the  drill  into  the  drill  hole,  although  results 
almost  as  good  may  be  obtained  by  equipping  the  present  type  of  dry  drill 
with  a  water  spray;  make  and  strictly  enforce  rules  against  squibbing  and 


PULMONARY   TUBERCULOSIS   IN   DUSTY    OCCUPATIONS  785 

boulder  popping  during  the  time  that  the  shift  is  underground,  and  against 
the  blowing  of  dry  holes  at  any  and  all  times;  thoroughly  wet  the  working 
faces  and  the  broken  rock  every  morning  and  again  at  noon  if  necessary; 
improve  ventilation  by  the  sinking  of  new  shafts  whenever  practicable. 

2.  Do  away  with  common  drinking  cups  and  kegs,  and  water  pipes  which 
allow  the  miner  to  bring  his  lips  in  contact  with  the  orifice. 

3.  Do  not  employ  as  shovelers  men  under  20  years  of  age. 

4.  Through  cooperation  among  the  operators  provide  a  maximum  daily 
tonnage  for  shovelers  so  that  they  cannot  injure  their  health  through  over- 
work. 

5.  Provide  a  warm,  dry  and  clean  place  in  which  the  miners  may  change 
their  clothes. 

6.  Through  intensive  educational  campaigns  in  the  public  schools  and 
among  the  miners  themselves  disseminate  information  as  to  the  harmful 
effects  of  insanitary  practices  and  conditions,  such  as  crowded  living  quarters, 
overwork,  exposure,  dissipation,  the  breathing  of  air  polluted  by  powder 
fumes  and  rock  dust,  the  use  of  common  drinking  devices,  etc. 

The  most  scientific  and  exhaustive  investigations  into  the  problem  of 
miners'  phthisis  and  pulmonary  tuberculosis  have  been  made  in  South  Africa. 
In  a  recently  revised  report  of  a  commission  appointed  under  the  provisions 
of  the  "Miners'  Phthisis  Allowances  Act,"  including  a  statistical  appendix 
by  Dr.  G.  G.  Maynard,  all  the  essential  facts  of  the  problem  are  clearly  pre- 
sented with  reference  to  conditions  not  only  in  South  Africa  but  elsewhere 
throughout  the  world  wherever  deep  mining  in  quartz  rock  is  carried  on  to 
a  considerable  extent.  (For  a  copy  of  the  act,  "  To  make  provision  for  persons 
who  have  contracted  miners'  phthisis,"  by  the  Union  of  South  Africa,  see 
Bulletin  of  the  International  Labor  Office,  Vol.  IX,  Nos.  1-2,  1914.) 

VI.  Industrial  Phthisis 

The  more  special  aspects  of  the  industrial  dust  problem  cannot  be  ad- 
vantageously discussed  with  brevity.  Every  dusty  trade  presents  a  problem 
in  itself.  As  a  first  prerequisite  for  an  improvement  in  existing  health  condi- 
tions in  industry  it  is  essential  that  the  exact  conditions  and  processes  be 
thoroughly  understood  and  made  a  matter  of  record.  As  a  typical  illustra- 
tion of  what  is  necessary  in  this  direction  a  brief  reference  may  be  made  to 
the  "  Survey  of  Industrial  Health  Hazards  and  Occupational  Diseases  in 
Ohio."  The  first  results  of  this  investigation,  made  under  the  direction  of 
E.  R.  Hayhurst,  M.  D.,  and  published  by  the  Ohio  State  Board  of  Health, 
constitute  a  treatise  on  the  subject  of  industrial  diseases.  As  pointed  out 
in  this  report,  "Dust  may  be  inhaled  or  ingested,  or  aflfect  the  skin,  the  eyes 
and  the  ear  canals.  The  daily  subjection  to  dust,  for  more  than  brief 
intervals  at  a  time,  is  always  damaging.  The  skin  and  the  eyes  may  become 
physiologically  inured  to  it,  but  not  so  with  the  internal  organs.  The  least 
so 


786  STUDIES   RELATING   TO    OCCUPATIONAL   DISEASES 

harmful  dusts  are  those  arising  from  the  natural  earth  itself,  such  as  the  farmer 
is  subjected  to,  although  there  are  many  exceptions  to  this  in  the  case  of 
alkali,  sandy,  or  stony  earths,  etc.  White  flour  and  starch  appear  to  be 
practically  harmless  to  the  normal  person,  soapstone  dust  and  talc  may  be 
placed  next  in  order,  but  a  tuberculously  incHned  person  subject  to  these, 
if  they  do  no  more  than  irritate  the  nose  and  throat  and  promote  coughing, 
is  almost  certain  to  see  an  increment  in  his  disease.  Next  in  order  of  harm- 
fulness  come  wood  dust,  bran  dust,  coal  dust,  clay  dust,  ore  dust,  mineral 
dust  and  stone  dust.  It  will  be  seen  that  the  organic  dusts  are  the  least 
harmful.  Dusts  in  general  produce  a  chronic  catarrh  of  the  respiratory 
and  digestive  organs.  This  leads  to  a  fibrosis,  which  is  the  same  process  that 
is  gradually  brought  about  by  old  age.  These  catarrhs  and  fibroses  result  in 
lowered  resistance  of  the  damaged  parts  and*  invite  secondary  diseases, 
which  are  usually  the  cause  of  death." 

In  continuation  of  these  interesting  observations,  which  are  amplified 
by  illustrations  of  exhaust  systems  for  dust  removal  in  polishing  depart- 
ments, iron  and  steel  works,  etc.,  it  is  stated: 

"Two-thirds  of  a  pint  of  coal  dust  has  been  found  in  the  lungs  of  a  former  coal  miner. 
One-third  of  the  weight  of  the  lungs  of  a  rock-driller  has  been  found  to  consist  of  rock  dust. 
Probably  the  most  harmful  dust  of  all,  with  the  exception  of  poisonous  dust,  is  emery- 
dust,  which  is  composed  of  exceedingly  hard,  crystalline,  sharp  particles;  next  to  this  comes 
sand  or  sandstone  dust,  to  which  workers  are  subjected  in  surfacing,  polishing  and  crushing 
stone,  in  sand-blasting,  etc.  No  person  should  work  in  a  dusty  atmosphere.  *  Either  by 
mechanical  means,  wet  processes,  and  modification  of  processes,  or  by  personal  hygiene, 
as  respirators,  etc.,  dust  can  be  kept  out  of  the  human  system.  Dry  sweeping  during 
work  hours  is  a  most  vicious  practice.  Vacuum  cleaning  not  only  for  floors,  but  in  many 
dusty  processes,  is  especially  recommended.  In  dust  mixing  processes  much  of  the  mate- 
rial can  be  handled  by  vacuum  pipes  instead  of  scoop  shovels." 

VII.  General  Conclusions 

There  is  at  the  present  time  a  most  regrettable  neglect  on  the  part  of 
practically  all  local  health  authorities  to  take  proper  cognizance  of  the  health- 
injurious  consequences  of  dust  and  to  insist  upon  measures  of  effective  pre- 
vention and  control.  The  initial  work  which  has  been  done  in  this  respect 
by  the  State  Board  of  Health  of  Massachusetts  and  the  State  Depart- 
ment of  Labor  of  New  Jersey  is  deserving  of  most  careful  consideration. 
As  yet,  however,  no  state  or  local  board  of  health,  or  department  of  labor  and 
factory  inspection,  in  the  United  States  has  followed  the  thorough-going 
English  methods,  as  best  emphasized  in  the  annual  reports  of  the  Chief  In- 
spector of  Factories.  The  work  of  this  department  is  intelligently  coordinated 
to  the  efforts  of  local  boards  of  health,  as  perhaps  best  illustrated  by  the  ex- 

*  This  suggestion  of  course  must  not  be  literally  construed,  since  all  atmosphere  con- 
tains more  or  less  dust,  some  of  which  is  naturally  relatively  harmless.  By  a  dusty  at- 
mosphere is  meant  one  which  is  contaminated  by  dust  of  known  or  ascertainable  health- 
injurious  qualities. 


PULMONARY   TUBERCULOSIS    IX   DUSTY   OCCUPATIONS  787 

tended  consideration  of  the  tuberculosis  problem  in  Aberdeen,  with  special 
reference  to  occupation,  and  particularly  the  stone  industry,  which  is  of 
considerable  extent  in  or  near  to  the  city  of  Aberdeen.  Mention  also  requires 
to  be  made  of  what  has  been  done  by  the  United  States  Bureau  of  Labor 
Statistics  in  giving  publicity  to  the  results  of  special  investigations  into  the 
mortality  from  tuberculosis  in  dusty  trades,  and  to  the  American  Museum 
of  Safety  for  exhibiting  dust-preventive  devices  and  models  of  industrial 
diseases,  including  fibroid  phthisis.  A  concise  summary  of  the  entire  subject 
of  dust  and  fumes  as  foes  of  industrial  life  is  contained  in  an  address  delivered 
before  the  15th  International  Congress  on  Hygiene  and  Demography  by 
Sir  Thomas  Oliver,  M.  D.,  of  Newcastle-upon-Tyne. 

The  statistical  aspects  of  the  problem  have  been  discussed  briefly  in  my 
address  on  "Industrial  Accidents  and  Trade  Diseases  in  the  United  States," 
delivered  on  the  same  occasion,  and  earlier  in  my  two  papers  on  the  mortality 
from  consumption  in  dusty  trades,  published  respectively  as  Bulletins  79  and 
82  of  the  U.  S.  Bureau  of  Labor.  The  results  of  all  inquiries  into  the  problem 
of  industrial  dust  emphatically  and  unequivocally  suggest  the  supreme  im- 
portance of  a  clear  reaUzation  on  the  part  of  employers  and  employees  on  the 
one  hand  and  state  or  local  health  authorities  on  the  other,  that  a  vast  amount 
of  irreparable  damage  results  from  indifference  and  neglect  in  the  control  of 
the  dust  nuisance,  the  harmfulness  of  which  is  but  imperfectly  realized  on  the 
part  of  those  most  seriously  affected  thereby.  The  solution  of  the  problem 
will  depend  largely  upon  the  intelligent  and  hearty  cooperation  of  federal, 
state,  and  local  health  authorities,  the  labor  bureaus  or  industrial  boards, 
and  most  of  all  the  employers  and  employees,  who  are  most  familiar  with  the 
conditions  under  which  modern  industry  is  carried  on.  The  effective  control 
of  the  dust  factor  in  industry  and  the  gradual  elimination  of  health-injurious 
dusts  from  certain  well-defined  industrial  processes  must,  in  course  of  time, 
profoundly  affect  the  tuberculosis  death  rate  and  result  in  a  material  reduction 
of  the  mortality,  to  the  inestimable  advantage  of  the  community,  the  indus- 
tries and,  most  of  all,  the  workmen  themselves. 

REFERENCES 

Occupation  ^lortality  Statistics,  Decennial  Supplement  to  the  Reports  of  the  Registrar 
General,  1900-1902. 

Occupation  Mortality  Statistics,  U.  S.  Registration  Area,  Reports  of  Division  of  Vital 
Statistics,  Washington,  1908-1909. 

Occupation  Mortality  Statistics,  Metropolitan  Life  Insurance  Company,  New  York,  Pro- 
ceedings American  Public  Health  Association,  19 15. 

Air  and  Life,  by  Henry  De  Varigny,  M.  D.,  Smithsonian  Miscellaneous  Collections,  Wash- 
ington, 1896. 

Atmosphere  in  relation  to  Human  Life  and  Health,  by  Francis  Albert  RoUo  Russell, 
Smithsonian  Miscellaneous  Collection,  Washington,  1896. 

The  DiEFerentiation  of  Black  Pigment  Found  in  the  Liver,  Spleen  and  Kidneys  from  Coal 
Dust  or  Other  Foreign  Deposits,  New  York  Medical  Record,  Aug.  10,  1907. 


788  STUDIES    RELATING    TO    OCCUPATIONAL    DISEASES 

Prevention  of  Tuberculosis,  by  Arthur  Newsholme,  New  York,  190S,  page  91  el  scq. 
Report  by  the  Medical  Officer  of  Health  of  the  City  of  Aberdeen  for  the  year  1909  with 

appendix  on  Tuberculosis. 
Mortality  from  Industrial  Diseases,  by  L.  W.  Hutchroft,  American  Journal  of  Public 

Hygiene,  February,  1909. 
Lung  Diseases  among  Sheffield  Grinders,  by  Harold  Scurfield,  M.  D.,  Transactions  Royal 

Sanitary  Institute,  London,   1910. 
Miners'   Consumption,  by  Otto  V.  Huffman,  Journal  American  Medical  Association, 

Nov.  26,  1910. 
Australian  Miners  and  Lung  Diseases,  The  British  Medical  Journal,  Jan.  7,  191 1. 
Hygiene  of  the  Steel  Trade,  by  J.  M.  Beattie,  Transactions  Royal  Sanitary  Institute, 

27th  Congress,  page  176  et  seq.,  1912. 
Dusty  Air  and  111  Health,  by  Robert  Hessler,  Indianapolis,  191 2. 

Air  Impurities,  by  Charles  Baskerville,  Ph.  D.,  New  York  Medical  Journal,  Nov.  30,  191 2. 
Report  on  Miners'  Phthisis  and  Pulmonary  Tuberculosis  in    Mines  within  the  Union 

of  South  Africa,  Cape  Town,  19 12. 
Lung  Diseases  among  Quarrymen,  The  British  Medical  Journal,  Mar.  23,  191 2. 
Study  of  the  Hygienic  Condition  of  the  Air  in  Textile  Mills  with  Reference  to  the  Influence 

of  Artificial  Humidification,  Monthly  Bulletin  Massachusetts  State  Board  of  Health, 

July,  1 9 13. 
The  Influence  of  the  Atmosphere  on  our  Health  and  Comfort  in  Confined  and  Crowded 

Places,  by  Hill,  Flack,  Mcintosh,  Rowlands  and  Walker,  Smithsonian  Miscellaneous 

Collections,  Washington,  1913. 
Atmospheric  Air  in  Relation  to  Tuberculosis,  by  Guy  Hinsdale,  A.  M.,  M.  D.,  Smith- 
sonian Miscellaneous  Collectiors,  Washington,  1914. 
The  Microbic  Content  of  Indoor  and  Outdoor  Air,  by  C.  E.  A.  Winslow  and  W.  W.  Browne, 

Monthly  Weather  Review,  July,  1914. 
Fresh  Air,  by  Frederick  S.  Lee,  Popular  Science  Monthly,  April,  1914. 
What  is  Meant  by  Industrial  Tuberculosis,  Monthly  Bulletin,  Ohio  Board  of  Health, 

September,  1914. 
Transactions  Chamber  of  Mines,  25th  Annual   Report  Transvaal  Chamber  of    Mines, 

Johannesburg,  1914.     (This  contains  the  report  by  Dr.  Gorgas.) 
Prevalence  of  Pneumonia  among  the  Native  Laborers  on  the  Rand,  The  Lancet,  May  2, 

1914.  ' 
Miners'  Phthisis  on  the  Rand,  by  J.  L.  Amyard,  Journal  of  Tropical  Medicine  and  Hygiene 

Apr.  15,  1914. 
Pulmonary  Disease  among  Miners  in  the  Joplin  District,  Missouri,  by  A.  J.  Lanza  and 

Edwin  Higgins,  Techinical  Paper  105,  U.  S.  Bureau  of  Mines,  1915. 
Respirators  vs.  Water  Sprays,  Engineering  and  Mining  Journal,  Nov.  20,  1915. 
Reports  of  the  Royal  Commission  on  Ventilation. 


CHAPTER  II 
THE  USE  AND  THE  FALLACIES  OF  STATISTICS 

BY  GEORGE  C.  WHIPPLE,  S.  B.,  Cambridge,  Mass. 

The  Use  and  the  Fallacies  of  Statistics. — Statistics  are  facts  expressed 
in  numbers,  collected  and  arranged  for  study.  When  there  are  few  facts  to 
be  considered  statistics  are  not  necessary;  the  mind  does  not  need  this  aid. 
Suppose  one  asks  the  wages  of  the  five  men  who  work  for  Smith.  The  reply 
is  easily  given  and  understood  if  the  facts  are  known:  Tom  gets  $15  a  week, 
George  and  Henry  receive  $12  each,  and  Bill  and  Mike  get  $10  each.  But 
suppose  one  asks  the  wages  of  the  laborers  in  a  large  factory  where  several 
thousand  men  are  employed.  We  might  go  through  the  list  in  the  same  way 
— in  fact  the  paymaster  is  obliged  to  do  so — ^but  for  purposes  of  study  we 
must  generalize  and  say  that  so  many  men  get  $15  a  week  each,  so  many 
more  get  $12  each,  and  so  on,  expressing  the  results  in  figures.  This  is  the 
statistical  method — to  enumerate,  to  classify  and  to  compare. 

As  the  number  of  different  facts  to  be  considered  in  any  problem  increases, 
the  need  of  studying  them  by  the  numerical  method  becomes  constantly 
greater  and  we  are  obliged  to  resort  to  arithmetical  processes  of  various  kinds. 
Sometimes  we  are  compelled  to  use  quite  complicated  mathematical  methods, 
but  the  mathematics  required  in  most  statistical  work  are  very  simple. 

The  great  danger  in  all  this  work  is  that  in  our  consideration  of  the  num- 
bers we  may  lose  sight  of  the  facts  for  which  they  stand,  in  the  same  way  that 
the  countryman  could  not  see  the  city  because  there  were  so  many  houses. 
Failure  to  visualize  is  the  besetting  sin  of  those  who  deal  with  facts  in  this 
abstract  way.  But  if  it  is  hard  for  the  statistician  it  is  even  harder  for  per- 
sons who  are  not  familiar  with  statistical  methods  to  visualize  when  the  facts 
enumerated  are  scattered  in  time  or  place.  If  a  factory  burns  and  a  dozen 
girls  are  killed  it  is  regarded  as  a  tragedy,  people  shudder  and  demand  safe- 
guards that  will  make  a  repetition  of  the  accident  impossible;  but  if  the  same 
number  of  girls  had  been  killed  one  at  a  time  in  different  factories  from  the 
same  lack  of  adequate  fire  protection  the  world  would  make  no  comment, 
because  it  is  the  usual  order  of  nature  for  people  to  die  one  at  a  time.  It  is 
one  of  the  tasks  of  the  statistician  to  bring  together  such  scattered  facts  so 
that  they  may  be  visualized  and  their  true  significance  made  known.  Thus 
it  happens  that  occasional  typhoid  fever  epidemics  tend  to  reduce  the  total 
number  of  deaths  from  this  disease;  that  occasional  railroad  accidents  tend 
to  make  travel  safer;  and  that  occasional  conflagrations  tend  to  reduce  the 
total  loss  of  life  and  property  from  fire.     In  other  words,  because  of  our 

789 


790  STUDIES   RELATING   TO    OCCUPATIONAL   DISEASES 

failure  to  visualize  the  scattered  facts  our  actions  are  controlled  more  by  the 
occasional  occurrence  of  a  striking  incident  than  by  the  prosaic  little  happen- 
ings which  in  the  aggregate  are  of  much  greater  importance.  Constant 
dropping  wears  away  the  stone.  It  is  part  of  the  vital  statistician's  work  to 
enumerate  the  drops,  that  the  magnitude  of  the  force  at  work  may  be  appre- 
ciated. It  is  his  function  to  induce  people  to  substitute  action  based  on 
judgment  for  action  based  on  emotion. 

The  statistical  method  is  always  found  to  be  popular  and  useful  when 
people  are  interested  in  the  facts  considered.  The  boys  of  the  country  are 
statistical  encyclopedias  when  baseball  and  batting  averages  are  considered; 
merchants  follow  the  statistics  of  prices  and  sales  with  an  eye  keen  to 
the  main  issue;  while  the  poHtician  knows  almost  by  heart  the  votes  for 
all  the  candidates  in  the  election  districts  under  his  charge.  Yet,  taken  as 
a  whole,  it  cannot  be  said  that  the  art  of  using  statistics  has  become  so  well 
developed  that  the  general  public  appreciates  it.  In  fact,  the  contrary  ap- 
pears to  be  the  case.  President  Kirkland  of  Harvard  College  used  to  say : "  the 
chief  use  of  statistics  is  to  refute  other  statistics,"  and  everyone  has  heard 
the  apothegm  that  "figures  will  not  lie,  but  liars  will  figure."  There  are 
several  reasons  for  this  state  of  mind  in  regard  to  the  use  of  statistics,  but 
three  of  them  stand  out  prominently:  first,  the  data  are  not  presented  clearly 
and  in  an  interesting  way;  second,  the  data  are  not  used  in  a  logical  manner; 
and  third,  the  reader  fails  to  make  the  necessary  mental  effort  to  understand 
and  visualize  the  facts  for  which  the  numbers  stand.  The  writer  believes 
that  vital  statistics,  in  order  to  be  of  practical  benefit,  must  be  used  with 
truth,  with  imagination  and  with  power. 

Again,  we  may  apply  to  statistical  proof  the  two  fundamental  requisites 
which  we  learned  in  our  study  of  geometry  and  which  are  expressed  in  the 
words  "necessary  and  sufficient." 

The  Statistical  Method. — The  statistical  method  involves  three  funda- 
mental processes — enumeration,  classification  and  comparison.  Or,  as  the 
logician  might  say,  we  collect  the  data  and  then  abstract  them.  In  making 
these  studies  we  resort  to  various  devices;  we  arrange  our  data  in  tables;  we 
generalize  from  these  tabulations  by  computing  averages  and  medians  and 
modes;  we  illustrate  our  facts  by  diagrams  and  cartoons;  we  compare  the 
results  of  one  class  or  group  with  those  of  another  class  or  group;  we  express 
these  relations  by  mathematical  formulae  and  thus  determine  certain  laws 
or  show  the  absence  of  a  law.  In  all  of  these  processes  we  must  be  ever  on 
our  guard  against  fallacies  that  lurk  therein.     Let  us  consider  some  of  these. 

Enumerations. — Enumeration  is  counting — ^an  easy  process,  one  says. 
So  it  is  if  we  know  what  is  to  be  counted.  Here,  at  the  outset,  we  meet  our 
first  difficulty.  What  are  we  going  to  count?  It  depends  upon  the  defini- 
tion of  the  unit  under  consideration.  Suppose  we  are  enumerating  the 
dwelling-houses  in  a  city.  What  shall  we  regard  as  a  dwelling  house?  Is 
a  church  a  dwelling-house  if  the  sexton  lives  in  it,  or  a  stable  if  the  hostler 


THE    USE    AND    THE    FALLACIES    OF    STATISTICS  79 1 

dwells  there?  Is  a  single  building  with  two  front  doors  one  dwelling-house 
or  two?  Is  a  "three  decker"  one  house  or  three?  It  will  be  seen  that  the 
term  "  dweUing-house,"  famihar  as  it  is  to  us,  needs  exact  definition  if  it  is 
to  be  used  as  a  basis  for  statistical  study. 

Again  let  us  suppose  that  we  are  studying  the  effect  of  the  environment 
in  a  cotton  mill  on  the  health  of  the  operatives.  Whom  shall  we  consider 
to  be  an  operative?  Shall  we  include  only  those  who  work  in  the  rooms  where 
cotton  is  made  or  shall  we  include  also  the  machinists  and  packers  and  the 
watchmen  and  the  clerks  in  the  office  ?  And  if  we  take  only  the  cotton  work- 
ers shall  we  take  into  account  the  period  of  time  that  they  have  been  em- 
ployed? If  a  man  has  worked  in  the  mill  only  a  week  ought  he  to  be  in- 
cluded? Obviously  these  matters  must  be  decided  before  the  enumeration 
is  begun.  Many  statistical  studies  are  worthless  because  of  failure  to  prop- 
erly define  the  units  in  the  beginning.  If  the  reader  wished  to  obtain  an 
illustration  of  the  difficulty  of  enumerating  people  in  well-defined  groups  let 
him  ask  three  or  four  of  his  friends  to  count  the  number  of  well-dressed  men 
or  the  number  of  beautiful  women  in  an  assembly.  The  results  will  tend  to 
make  him  conservative,  and  perhaps  pessimistic,  as  to  the  usefulness  of  the 
statistical  method. 

A  second  source  of  error  in  enumeration  is  failure  to  find  the  units  to  be 
counted.  In  taking  a  census  some  persons  are  never  found  by  the  enumera- 
tors. At  the  last  census  in  England,  where  the  census  is  taken  on  a  given 
night,  it  is  said  that  some  of  the  suffragettes  walked  the  streets  all  night  so 
as  not  to  be  counted,  arguing  that  if  they  could  not  vote  they  would  not  be 
counted.  It  is  well  known  that  birth  records  are  incomplete  in  all  countries, 
and  that  cases  of  reportable  contagious  diseases  are  not  reported  in  full  or  any- 
where near  it.  On  the  other  hand,  there  is  the  contrary  danger  that  the  same 
unit  may  be  counted  twice.  This  may  result  from  accident  or  carelessness; 
but  padded  census  records,  counts  of  tissue  ballots  and  all  sorts  of  tricky 
methods  are  at  times  resorted  to  by  the  unscrupulous.  An  old  darkey  selling 
eggs  used  to  count  them  thus:  "one,  two,  three,  four,  sLx,  seven,  eleven, 
fourteen,"  and  so  on.  The  process  of  enumeration  which  is  our  fundamental 
statistical  process  should  be  regarded  as  the  accurate  counting  of  well-defined 
units. 

There  is  a  rather  peculiar  form  of  error,  which  often  creeps  into  statistical 
enumerations,  known  as  the  error  of  round  numbers.  Thus  in  recording 
dates  of  past  events  some  will  be  given  on  the  exact  day  of  occurrence,  but 
where  memory  fails,  some  will  be  given  approximately  as  "on  the  first  of  the 
month,"  or  "  on  the  fifth,  tenth,  fifteenth  "  and  so  on.  This  causes  a  prepon- 
derance of  numbers  recorded  on  these  days.  The  same  is  true  in  regard  to  age. 
A  person  who  is  39  or  41  years  of  age  may  state  his  age  as  40,  a  round  number 
which  to  his  mind  is  near  enough.  The  tendency  to  this  error  may  be  dis- 
covered by  finding  that  an  undue  proportion  of  the  collected  figures  are  divis- 
ible by  5  or  10  or  100.     Another  means  of  discovery  is  by  plotting  the  data. 


792 


STUDIES   RELATING   TO    OCCUPATIONAL   DISEASES 


Classifications. — There  are  three  general  methods  of  studying  statistical 
enumerations.  First,  there  is  the  complete  statistical  study,  which  includes  a 
full  account  of  all  the  units  within  the  desired  area  or  within  the  specified 
time.  This  method,  of  course,  brings  the  surest  results  and  can  often  be 
employed  when  the  study  is  not  too  extensive.  Often  it  is  impracticable. 
Second  is  the  monogramic  method,  a  procedure  in  which  a  detailed  and  exact 
study  is  made  of  a  particular  group.  When  the  group  selected  for  study  is  a 
well  chosen  type  the  application  of  this  method  yields  valuable  results,  but 
there  is  always  a  danger  in  generahzing  from  monographic  researches.  The 
third  method  is  the  representative  method,  as  the  method  of  sampling,  when  a 
selected  part  is  taken  as  representative  of  the  whole.  The  value  of  this 
method  is  dependent  upon  the  accuracy  of  the  sampling  process,  often  a  diffi- 
cult matter  to  negotiate.  Sampling  may  be  by  ramdom  selection,  or  by  mixture 
and  subdivision.  In  any  sampling  process  there  is  always  a  tendency  to  take 
the  obvious  and  the  accessible,  and  this  may  cause  the  sample  to  be  unrepre- 
sentative; or  one  may  be  governed  in  his  sampling,  consciously  or  uncon- 
sciously, by  some  preconceived  notion  as  to  the  probable  results  or  the  desired 
results. 

The  technique  of  statistical  induction,  says  Royce,  consists  in  learning, 
first,  how  to  take  fair  samples  of  the  facts  in  question  and,  second,  how  to 
observe  these  facts  accurately  and  adequately. 

In  classifying  the  data  we  arrange  them  in  sections,  classes,  groups,  and 
series  for  purposes  of  comparison.  Collections  of  units  differing  from  other 
collections  by  characteristics  not  expressed  in  figures  are  termed  sections  or 
classes.  Thus,  populations  are  divided  into  classes  according  to  sex,  nation- 
ality, conjugal  condition,  civil  divisions.  Collections  of  units  differing  from 
other  collections  by  characteristics  expressed  in  figures  are  called  groups.  As 
an  example,  population  is  divided  into  age  groups  or  into  groups  of  persons 
having  different  weights  or  heights.  In  generalizing,  the  average  is  found 
for  each  group  and  these  are  compared  with  each  other  and  with  the  whole. 
Data  are  also  arranged  in  series  according  to  some  natural  sequence  or  some 
order  of  magnitude  or  chronological  order. 

The  difference  between  a  class  and  a  group  is  well  illustrated  by  a  little 
joke  that  recently  appeared  in  one  of  the  papers.  The  question  was  asked, 
"What  class  of  people  live  to  be  the  oldest?"  The  answer  was,  "Cente- 
narians." The  reader  will  recognize  that  this  witty  reply  was  not  responsive 
to  the  question,  in  that  centenarians  represent  a  "group"  of  people,  not  a 
"class." 

Tabulation. — For  purposes  of  study  and  display  the  collected  data  are 
commonly  arranged  in  tabular  form.  The  preparation  of  tables  is  an  im- 
portant part  of  statistical  work  and  cannot  be  done  too  well.  Essential  quali- 
ties of  good  tabular  work  are  clearness,  compactness,  and  neatness.  In  the 
first  place  every  table  should  have  a  title  that  describes  clearly  what  the  data 
are.     Preferably  it^should^be  as  short  as  possible  and  it  is  good  training_in 


THE   USE    AND    THE    FALLACIES    OF    STATISTICS  793 

the  use  of  words  to  produce  an  artistic  title.  Each  column  should  also  have 
a  clear  and  appropriate  title,  in  which  well  understood  or  well  explained  abbre- 
viations may  be  used  if  it  is  necessary  to  save  space.  Where  the  heading  is 
complex,  that  is,  where  certain  parts  of  the  heading  cover  more  than  one 
column,  care  should  be  taken  to  have  this  clearly  indicated  by  proper  ruling. 
Where  different  columns  are  referred  to  in  the  text  accompanying  the  table 
it  may  be  found  convenient  to  give  each  column  a  serial  number,  from  left  to 
right,  placed  in  parenthesis  just  below  or  above  the  heading.  Long  unbroken 
columns  of  figures  are  confusing  to  the  eye  and  horizontal  spaces  between 
every  five  lines  are  often  left.     This  practice  is  to  be  commended. 

Ratios — Rates. — Ratios  may  be  expressed  by  common  fractions  or  by  deci- 
mals. It  is  seldom  wise  to  use  common  fractions  of  which  the  denominator  is 
greater  than  10,  unless  it  is  some  commonly  used  multiple  of  5  or  10,  such  as 
3^^5  or  /-^OO-  In  statistical  tabulations  decimals  should  be  used.  Rates  are 
merely  ratios  in  which  the  basis  of  comparison  is  some  well-recognized  division 
of  area  or  time  or  some  common  unit  of  the  decimal  system.  Examples: 
gallons  of  water  per  day,  persons  per  square  mile,  number  of  births  per  1000 
marriages.  Compound  rates  are  commonly  used  when  comparison  is  made 
with  two  bases:  thus,  gallons  per  capita  per  day,  number  of  births  per 
1000  marriages  per  annum.  Most  of  the  rates  used  for  the  comparison  of 
vital  statistics  are  compound  rates  as  they  involve  both  area  and  time. 
Sometimes  these  are  termed  compound  averages. 

Misuse  of  Averages  and  Rates. — Fictitious  accuracy  should  be  avoided. 
If  35  out  of  57  balls  were  white  the  percentage  of  white  balls  would  be  61.40 
per  cent.  The  smallest  possible  error,  i.e.,  i,  would  change  the  percentage 
to  59.65  per  cent,  or  63.16  per  cent.  Clearly  for  figures  less  than  100  frac- 
tions of  per  cents,  are  illogical.  In  the  same  way  death  rates  for  populations 
of  less  than  1000  are  useless  beyond  the  third  significant  figure.  Comparisons 
of  averages  of  fictitious  value  are  also  to  be  avoided. 

Changes  of  basis  in  the  computation  of  rates  should  be  kept  in  mind  in 
order  to  avoid  error  of  statement.  Thus,  in  the  j^ear  1880  the  receipts  of  a 
water  company  were  $400,000;  between  1880  and  1890  they  decreased  10 
per  cent.,  so  that  between  1890  and  1900  they  became  $396,000  (not 
$400,000).  The  basis  used  should  be  stated  in  words  if  it  is  not  perfectly 
clear  from  the  context. 

When  interpreting  ratios  it  should  be  carefully  noted  whether  the  numera- 
tor bears  a  direct  relation  to  the  denominator.  In  proportion  as  it  fails  to  do 
so,  any  inference  from  it  is  less  valuable.  For  example,  the  ratio  between  the 
number  of  births  and  the  total  population  is  less  close  than  between  the  num- 
ber of  births  and  the  number  of  married  females  of  child-bearing  age.  In 
the  same  way  crude  death  rates  based  on  total  population  regardless  of  sex 
or  age  are  less  useful  in  studying  relative  hygienic  conditions  than  when  age 
and  sex  are  taken  into  account.  It  is  failure  to  take  this  element  into  account 
that  has  led  people  to  say,  "You  can  prove  anything  by  statistics,"  and  that 
has  given  unscrupulous  persons  opportunity  to  deceive  the  unthinking  or 


794  STUDIES   RELATING   TO    OCCUPATIONAL   DISEASES 

the  uninformed.  A  moral  responsibility  of  no  mean  order  thus  rests  upon 
the  statistician. 

Ratios  are  sometimes  necessarily  used  in  an  indirect  way.  Thus,  the 
average  annual  exports  and  imports  are  taken  to  represent  the  business  con- 
dition of  a  country.  Here  a  part  is  taken  for  the  whole.  The  method  is 
proper  if  in  the  interpretation  it  is  recognized  that  it  is  a  part.  Or  the  typhoid 
fever  death  rate  of  a  city  is  taken  as  an  index  of  the  sanitary  quality  of  the 
public  water  supply.     It  may  be  indeed  such  an  index,  but  it  is  only  one. 

Another  danger  is  that  common  to  all  forms  of  reasoning,  namely,  that 
of  using  post  hoc  for  propter  hoc.  This  fallacy  is  very  likely  to  creep  in  un- 
awares in  statistical  work  under  cover  of  apparent  accuracy  and  thorough- 
ness of  investigation  imphed  by  the  use  of  columns  of  figures.  Bailey  has  well 
said  that  "the  phrase  'other  things  being  equal'  has  covered  up  a  multitude 
of  sins.  As  a  rule  other  things  are  not  equal."  It  is  even  worse,  perhaps, 
to  take  it  for  granted  that  other  things  are  equal.  Bailey  also  warns  against 
the  hidden  errors  that  may  lie  under  the  use  of  the  terms  "it  is  undoubtedly 
true  that,  etc.,"  and  "it  is  probably  the  case  that,  etc."  Of  vital  importance 
is  it,  therefore,  to  make  sure  that  the  data  collected  are  sufficient  in  kind  and 
number  for  the  purpose  for  which  the  statistics  are  intended.  It  saves  time 
and  labor  in  the  end  to  consider  carefully  at  the  outset  just  what  data  are 
needed.  Where,  as  is  often  the  case,  the  statistician  had  no  control  over  the 
collection  of  the  data,  he  should  make  every  possible  attempt  to  ascertain 
the  reliability  of  the  sources  of  information  and  not  attempt  to  draw  con- 
clusions not  warranted  by  the  conditions  under  which  the  figures  were  col- 
lected.    The  statistician  cannot  safely  write  newspaper  headlines. 

The  Index. — Averages  of  different  groups  and  even  of  different  classes 
are  sometimes  combined  to  give  a  single  ratio,  more  convenient  for  use  and 
perhaps  more  accurate  as  a  measure  of  certain  phenomena.  Thus,  the  prices 
of  various  standard  commodities  sold  in  any  year  are  combined  to  give  a  single 
figure  that  is  taken  to  indicate  the  state  of  trade  during  that  year.  This 
may  be  done  by  taking  a  weighted  average  of  the  different  articles  sold  in 
any  one  year  and  comparing  it  with  the  weighted  average  for  some  particular 
year  or  series  of  years  taken  as  a  standard.  Obviously  there  are  various 
ways  in  which  an  index  can  be  prepared. 

The  index  has  not  come  into  use  to  any  extent  in  the  study  of  vital  sta- 
tistics, but  it  would  seem  logical  to  use  it  in  comparing  the  relative  hygienic 
conditions  of  different  cities.  This  is  to  a  certain  extent  accomplished  when 
crude  death  rates  are  adjusted  to  take  into  account  the  composition  of  popu- 
lation, as  to  age,  sex  and  nationahty. 

Variations. — In  the  treatment  of  objects  or  organisms  that  belong  to 
some  definite  group  or  in  the  observation  of  natural  phenomena  it  is  com- 
monly found  that  the  results  are  much  alike,  although  not  precisely  aUke. 
Thus,  the  heights  of  most  men  are  quite  near  the  average  of  all,  but  a  few 
men  are  above  the  average  height  and  a  few  below  it.     The  same  is  true  of 


THE    USE    AND    THE    FALLACIES    OF    STATISTICS  795 

the  weights  of  persons  in  any  age  group.  It  is  true  of  the  ages  at  which  people 
die  from  different  causes.  And  so  in  many  of  the  phenomena  that  come 
under  the  head  of  vital  statistics  many  observations  will  be  found  near  the 
average  of  all,  but  a  few  will  be  quite  different.  These  variations  commonly 
follow  certain  mathematical  laws  of  probability  which  are  found  to  be  quite 
useful  in  statistical  work.  The  study  of  variations  is  fascinating  in  itself. 
It  has  already  played  a  large  part  in  biological  investigations  and  Kttle  by 
little  the  idea  is  being  extended  into  the  engineering  sciences.  For  example, 
it  has  been  found  that  the  frequency  of  rainfalls  of  different  magnitudes  can 
be  expressed  in  accordance  with  the  law  of  probability,  and  the  same  is  true 
of  the  occurrence  of  floods,  and  similar  natural  phenomena. 

In  this  brief  chapter  it  is  impossible  to  discuss  this  interesting  subject 
of  variation  and  frequency,  but  the  reader  is  urged  to  pursue  it  in  the  standard 
teXt-books  on  Statistics  and  Least  Squares. 

Death  Rates. — A  figure  commonly  used  in  sanitary  and  hygienic  studies 
is  the  death  rate.  By  this  is  meant  the  ratio  between  the  number  of  persons 
dying  in  a  given  period  of  time  and  place,  and  the  number  of  persons  in  the 
place  alive  at  the  middle  of  the  period,  referred  to  some  round  number,  as 
1000  or  10,000  or  100,000  as  the  basis  of  camparison.  Unless  otherwise 
specified  the  period  of  time  is  taken  as  i  year.  When  considering  deaths 
from  all  causes  the  basis  of  population  is  taken  as  1000,  but  when  considering 
deaths  from  particular  causes  100,000  makes  a  better  basis  for  comparison. 

In  a  certain  city  in  the  year  1910  there  were  5710  deaths  from  all  causes. 
The  population  was  390,000,  consequently  for  every  thousand  population 
the  number  of  deaths  was  5710  divided  by  390  thousands,  or  14.6.  This  rep- 
resents the  general  death  rate,  or  the  crude  death  rate,  as  it  is  often  called. 
Such  a  rate  enables  us  to  compare  on  the  same  basis  the  mortality  for  places 
of  different  size.  It  is  a  convenient  yard  stick,  but  it  must  be  used  with 
great  caution.  It  is  often  misused.  The  expression  "crude  death  rate" 
is  to  be  taken  literally  for  such  a  rate  is  indeed  a  very  crude  one. 

Let  us  consider,  for  a  moment,  how  it  is  made  up.  In  the  first  instance 
it  is  a  common  fraction,  and  has  a  numerator  and  a  denominator.  The 
numerator  is  the  number  of  deaths  at  all  ages,  from  all  causes,  from  all  sorts 
of  occupations,  in  all  kinds  of  houses,  the  only  boundary  of  the  group  being 
that  the  deaths  occurred  within  the  given  place  and  within  the  period  of  a 
calendar  year.  Presumably,  it  includes  all  the  deaths  there  were,  but  even 
this  is  not  always  the  case.  Suppose  a  child  is  born  dead,  or,  as  we  say,  is 
still-born;  is  this  still-birth  included  among  the  deaths?  In  some  places  it 
has  been  so  included.  Modern  statistical  practice  does  not  include  it. 
Again,  suppose  a  person  whose  home  is  in  the  given  place  dies  away  from 
home  and  is  brought  home  for  burial,  or  that  another  dies  in  a  hospital  within 
the  given  place  and  is  buried  outside  of  the  place.  Here  are  other  chances 
for  uncertainty.  Hence,  the  numerator  of  our  death-rate  fraction  is  more 
or  less  unreHable  and  ambiguous. 


796  STUDIES    RELATING   TO    OCCUPATIONAL   DISEASES 

The  denominator  is  equally  so.  Except  in  years  when  a  census  is  taken 
the  mid-year  population  must  be  estimated,  and  this  estimate  may  be  wide  of 
the  mark.  The  natural  tendency  is  for  population  to  increase  at  a  geo- 
metrical rate,  that  is,  to  increase  like  compound  interest,  but  actually  the 
population  of  a  given  place  changes  from  various  other  causes  which  mask 
this  normal  rate  of  increase,  from  emigration  and  immigration  and  from 
changes  in  the  birth  rate.  These  changes  .are  of  ten  sudden  and  large.  The 
United  States  Census  Bureau  makes  a  practice  of  estimating  that  between 
the  census  years  the  population  in  any  given  place  increases  or  decreases 
by  a  constant  annual  increment.  On  the  whole,  this  may  be  true  and  it  is 
probably  the  best  general  rule  to  follow  in  this  country  at  the  present  time, 
but  in  any  given  place  it  may  be  wide  of  the  mark,  and  the  denominator  of 
our  fraction  may  therefore  be  wrong  in  any  particular  year.  But  even  if 
correct,  the  denominator  stands  for  a  composite  population  and  includes  the 
young  and  the  old,  male  and  female,  the  rich  and  the  poor,  the  well  and  the 
sick,  the  native  and  the  foreign.  The  only  boundary  of  the  group  is  that 
the  persons  included  must  be  ahve  and  living  in  the  given  place  at  mid-year. 

The  general  death  rate,  therefore,  is  an  imperfect  measure  of  hygienic 
and  sanitary  conditions  except  betweeri  groups  of  population  similar  in 
character.  The  crude  death  rate  of  a  manufacturing  city  like  Lawrence, 
Mass.  cannot  be  fairly  compared  with  that  of  a  residential  city  like  Newton. 
The  general  death  rate  of  a  big  city,  with  its  large  middle-aged  population, 
cannot  be  compared  with  that  of  a  rural  county  deserted  by  the  middle-aged 
people  who  have  gone  to  the  city.  Chicago  cannot  be  fairly  compared  with 
Boston  on  this  basis,  nor  New  York  with  New  Orleans.  It  is  true  that  this 
is  done  repeatedly,  but  the  figures  mean  but  little,  and  the  conclusions  reached 
from  such  comparisons  are  often  false  and  mischievous. 

The  fallacy  in  the  general  death  rate  lies  partly  in  its  liability  to  error, 
but  still  more  in  the  composite  character  of  the  two  quantities  which  to- 
gether give  us  the  ratio. 

General  Death  Rate  Influenced  by  Infant  Mortality. — It  is  not  generally 
realized  that  about  one-fifth,  to  use  an  approximate  figure,  of  all  of  the  deaths 
in  a  given  year  are  of  children  less  than  a  year  old.  One-quarter  of  the  total 
deaths  are  almost  always  children  less  than  2  years  old.  Hence,  whatever 
influences  the  deaths  of  children  influences  very  greatly  the  general  death 
rate.  An  abnormally  hot  summer  may  do  this  or  an  epidemic  of  children's 
diseases. 

It  follows  also  that  a  high  birth  rate  results  in  a  higher  general  death 
rate  and  a  comparison  of  the  curves  of  birth  rates  and  general  death  rates 
shows  a  surprising  synchronism.  Birth  rates  and  marriage  rates  both  fluc- 
tuate with  the  general  death  rate. 

During  the  last  quarter  century  the  general  death  rates,  have  been  falling. 
This  has  been  due  in  great  measure  to  improving  sanitary  conditions  but  it 
has  been  due  also  to  lowering  birth  rates. 


THE    USE    AND    THE    FALLACIES    OF    STATISTICS  797 

In  this  connection,  however,  it  should  be  remembered  that  the  birth 
rate  influences  the  denominator  of  the  death-rate  fraction  as  well  as  the 
numerator,  for  most  of  the  children  born  do  not  die  at  an  early  age.  Were 
the  population  of  a  place  not  influenced  by  immigration  a  lowering  birth 
rate  would  not  continually  reduce  the  general  death  rate,  for  with  fewer 
children  born  there  would  be  a  smaller  population  upon  which  to  figure  the 
death  rate.  The  problem  is  endlessly  complicated  and  requires  a  deep 
mathematical  mind  for  its  full  comprehension.  It  is  sufficient  to  remember 
that  as  long  as  the  birth  rate  continues  to  fall  and  our  present  immigration 
keeps  up  so  long  will  the  crude  death  rates  continue  to  fall.  And  when  some 
years  hence  the  birth  rates  cease  to  fall,  as  they  must,  and  when  they  increase, 
as  it  is  to  be  hoped  they  will,  this  wull  be  accompanied  by  an  increase  in  the 
general  death  rate.  This  increase  in  the  death  rate  will  be  normal  and  must 
not  be  regarded  as  a  sign  of  failure  on  the  part  of  sanitation.  It  is  hardly  to 
be  expected  that  the  improvement  in  sanitation  will  prevent  this  ultimate 
increase  in  the  general  death  rates.  If  sanitarians  will  recognize  this  fact  to- 
day it  may  save  them  some  heart  burnings  in  years  to  come. 

Infant  Mortality  not  an  Index  of  Sanitary  Environment.^ — Studies  of  the 
death  rates  of  the  world  show  that  until  within  a  very  few  years  there  has 
been  no  substantial  decrease  in  infant  mortality,  and  this,  too,  in  spite  of 
the  fact  that  the  specific  death  rates  for  children  and  persons  up  to  middle 
life  have  materially  decreased.  The  lowering  of  the  death  rates  from  those 
diseases  which  are  caused  by  specific  infections  have  been  very  conspicuous 
for  a  generation,  and  this  is  clearly  due  to  improvements  in  sanitation  re- 
sulting from  our  better  knowledge  of  bacteriology.  Infant  mortality  does 
not  reflect  so  clearly  our  recent  efforts  to  obtain  a  clean  environment.  Hence, 
the  infant  mortality  of  itself  does  not  offer  a  satisfactory  index  of  sanitary 
conditions. 

The  decrease  in  infant  mortality  which  has  occurred  during  the  last 
5  or  lo  years  has  been  due  rather  to  the  various  activities  that  come  under 
the  heads  of  infant  welfare  and  motherhood  training.  It  is  important  to 
keep  the  distinction  between  this  work  and  the  work  of  sanitation  clearly  in 
mind.  A  study  was  made  in  Boston  a  few  years  ago  which  showed  marked 
variations  in  the  specific  death  rates  of  infants  at  different  ages.  The  data 
collected  were  tabulated  by  months  and  by  nationalities.  It  was  found 
that  the  Italian  infants  had  a  low  death  rate  during  the  first  few  months,  that 
is,  during  those  months  w^hen  the  children  were  being  nursed  by  the  mother, 
but  that  after  the  age  of  about  9  months  the  death  rates  began  to  increase, 
a  fact  that  was  apparently  due  to  the  child  entering  a  new  and  unclean  en- 
vironment. The  children  of  Jewish  parentage  maintained  a  relatively 
low  death  rate  for  a  long  period.  It  is  only  by  studying  vital  statistics  in  a 
detailed  way  that  such  facts  as  these  are  brought  to  light.  While  the  proc- 
esses of  generalization  are  of  value  the  opposite  processes  of  subdivision  and 
classification  are  equally  important. 


798  STUDIES   RELATING   TO    OCCUPATIONAL   DISEASES 

Restricted  Death  Rates.— Instead  of  computing  the  general  death  rate 
of  a  place  in  the  manner  indicated  we  may  restrict  either  the  numerator  or 
the  denominator  of  the  fraction.  We  may  limit  the  time  to  something  less 
than  a  year  and  thus  obtain  monthly  rates,  or  weekly  rates,  or  even  daily 
rates.  We  may  Hmit  the  deaths  to  those  from  a  particular  cause,  and  obtain 
the  annual  death  rate  from  tuberculosis  or  from  typhoid  fever,  or  from 
lead  poisoning.  Or  we  may  limit  the  group  or  class  represented  by  the 
denominator  to  certain  ages  or  occupations  or  nationality  or  sex,  and  in 
various  ways  we  may  obtain  rates  that  are  useful  for  study  and  comparison. 
These  rates  may  have  in  common  scarcely  anything  more  than  that  they  are 
referred  to  some  round  number  as  loo,  or  looo,  or  100,000  as  the  basis  of 
comparison,  or  in  other  words  that  they  are  expressed  by  the  decimal  system. 
Such  rates  we  term  "specific  rates"  for  the  reason  that  they  include  only 
the  data  for  definitely  specified  groups  or  classes. 

In  making  up  these  restricted  or  specific  death  rates  and  in  comparing 
them  it  is  of  the  greatest  importance  to  make  sure  that  in  restricting  a  group 
by  one  set  of  boundaries  we  do  not  at  the  same  time  and  without  knowing 
it,  perhaps,  restrict  it  by  other  boundaries.  Thus,  by  dividing  the  in- 
structing staff  of  a  university  into  classes  such  as  assistants,  instructors,  assist- 
ant professors,  associate  professors,  and  full  professors,  we  may  at  the  same 
time  be  estabhshing  a  grouping  according  to  age.  In  dividing  the  workmen 
employed  by  a  city  into  policemen  and  laborers,  we  might  at  the  same  time 
be  dividing  them  by  nationahty  into  Irish  men  and  Italians.  This  is  a  fallacy 
against  which  those  who  use  statistics  must  be  continually  on  their  guard. 
In  very  many  cases  age  comes  in  as  a  disturbing  factor.  Scores  of  in- 
stances might  be  given.  Why  is  the  death  rate  so  high  among  bank  presi- 
dents? Not  because  the  occupation  is  hazardous,  but  because  this  posi- 
tion is  commonly  meted  out  only  to  men  of  mature  years.  By  the  same  token 
the  average  age  at  death  of  bank  presidents  is  said  to  be  high.  The  average 
age  at  death  of  lady  stenographers  is  low.  W^hy?  Not  because  the  use  of 
shorthand  and  the  hammering  of  the  keys  tends  to  premature  death,  but 
because  so  large  a  percentage  of  lady  stenographers  marry  and  take  them- 
selves out  of  the  group  of  stenographers  before  they  attain  an  advanced  age. 
To  a  very  considerable  extent  classification  by  occupation  results  automatically 
in  an  age  grouping.  For  example,  the  average  death  rate  of  newsboys  is 
low.  W^hy?  Because  all  newsboys  are  young.  The  average  death  rate  of 
civil  war  veterans  is  high.  Why?  Because  the  entire  class  is  now  com- 
posed of  old  men.  Likewise,  certain  diseases  are  most  commonly  asso- 
ciated with  certain  age  periods,  and  some  diseases  are  confined  exclusively 
to  one  sex. 

Hence,  in  tabulating  data  and  in  computing  rates  for  the  purpose  of 
measuring  the  importance  of  some  factor  one  should  endeavor  to  so  ar- 
range the  classification  as  to  leave  this  as  the  only  factor  that  varies.  They 
may  involve  a  more  detailed  study  than  we  are  in  the  habit  of  making,  and 


THE    USE   AND   THE    FALLACIES    OF    STATISTICS 


799 


it  is  not  always  possible  to  make  such  a  separation  of  the  data.  The  general 
principle  should,  however,  always  be  borne  in  mind.  Often  an  age  group- 
ing in  addition  to  some  other  classification  will  be  sufficient. 

Specific  Death  Rates. — The  variations  in  the  specific  death  rates  at 
different  age  groups  are  illustrated  by  Fig.  45,  in  which  it  will  be  seen  that 
the  death  rates  are  high  in  early  infancy.  They  decrease  rapidly  and 
attain  a  minimum  at  the  age  of  about  12  years,  then  they  slowly  increase 


SPEC/F/C  DEATH  RATES 
AT 

DIFFERENT  AGES 


0      20      30      40      50 

Age 

Fig.  45- 

until  the  age  of  60,  and  after  that,  of  course,  there  is  a  rapid  increase.  Curves 
like  this  are  much  more  satisfactory  for  comparing  the  sanitary  conditions  of 
different  cities  than  a  single  figure  representing  the  death  rate  can  possibly 
be,  because  one  may  obtain  at  a  single  glance  a  picture  of  the  conditions 
which  exist  at  any  age.  The  two  Hnes  in  the  diagram  show  the  change 
that  occurred  in  the  specific  death  rates  between  1890  and  1900  for  the  United 
States  Registration  Area.  It  will  be  seen  that  there  was  a  decrease  in  the 
rates  for  infants  and  children,  but  an  increase  in  the  specific  death  rate  above 
the  age  of  60. 


8oo 


STUDIES   RELATING   TO    OCCUPATIONAL   DISEASES 


Figure  46  is  equally  interesting.  It  shows  the  distribution  of  deaths  from 
all  causes  among  different  ages  in  Massachusetts  in  1910.  The  importance 
of  the  infant  mortality  as  compared  with  the  deaths  at  other  ages  is  strikingly 
evident.  ^ 

Display  of  Statistical  Data. — Having  made  an  accurate  and  sufficiently 
complete  enumeration  and  classification  of  the  data  and  compared  them  in 
a  logical  manner,  guarding  against  the  many  fallacies  that  lie  in  wait  to  catch 
the  unwary  one  thing  yet  remains — that  of  displaying  the  data  so  that  he 
who  runs  may  read,  or  as  the  farmer  said  when  he  put  up  a  sign  to  beware  of 
the  dog,  "  so  that  he  who  reads  may  run."     One  reason  why  statistics  produce 


so  little  effect  on  the  ordinary  reader  is  because  they  are  so  poorly  displayed. 
Even  in  tabulating  data  or  drawing  diagrams  to  illustrate  the  data  graphically 
it  is  possible  to  falsify  the  facts.  The  art  of  statistical  graphics  has  been 
learned  by  few  and  practised  by  a  still  smaller  number  of  vital  statisticians. 
And  the  pubhc  has  become  so  in  the  habit  of  seeing  diagrams  that  conceal 
and  mislead  rather  than  those  that  clearly  display  that  it  has  no  taste  for 
diagrams  that  are  really  well  drawn. 

Tabular  printing  is  expensive;  hence,  tables  should  be  made  as  simple  as 
possible,  with  short  cleats  headings  for  the  columns,  good  alignment,  with 
columns  numbered  for  convenient  reference,  and  above  all  with  a  title  that 

'Diagrams  were  drawn  by  Mr.  Sylvester  Schnatlschneider,  Assistant  in  Sanitary 
Engineering,  Harvard  University. 


THE    USE    AND    THE    FALLACIES    OF    STATISTICS  8oi 

tells  what  the  table  contains.  The  figures  should  not  be  allowed  to  sprawl 
over  a  page.  Where  there  are  but  two  or  three  columns  these  may  be  re- 
peated in  parallel  series,  unless  a  single  set  of  columns  is  needed  for  the  sake 
of  presenting  a  clearer  mental  picture.  Hundreds  of  dollars  are  wasted  every 
year  by  using  poorly  arranged  tables,  with  no  one  the  gainer  but  the  printer 
and  the  paper  maker. 

The  Future  of  Demography. — Demography  is  at  once  a  very  old  and  a 
very  new  study.  It  might  well  be  called  one  of  the  lost  arts.  Some  of  the 
reports  that  were  published  a  half  century  or  more  ago  might  almost  be  taken 
as  models  of  good  statistical  work.  An  excellent  example  is  the  report  of  the 
Massachusetts  Sanitary  Commission  of  1850,  which  was  prepared  by  Lemuel 
Shattuck.  The  vast  accumulation  of  data  in  recent  years  has  not  been  ac- 
companied by  an  improvement  in  the  art  of  classifying  and  studying  the  data. 
In  fact  there  has  been  of  late  something  of  a  retrogression.  A  very  large 
number  of  poorly  prepared  reports  containing  undigested  data  have  been 
issued.  The  statistical  work  has  been  crude  and  slipshod  and  has  tended  to 
bring  the  science  into  disrepute.  But  there  are  signs  of  a  change  for  the 
better.  In  this  movement  the  Bureau  of  the  Census  of  the  United  States  has 
been  a  conspicuous  leader. 

Aside  from  the  academic  value  of  the  science  of  demography  there  are 
immense  practical  values  which  are  just  beginning  to  be  realized.  For 
example,  we  have  come  to  learn  that  various  sanitary  reforms  are  tending 
to  increase  the  cost  of  living.  Pure  food,  pure  air,  and  pure  water  are  not 
obtained  without  expense.  Oftentimes  the  expense  is  fully  justified  and  the 
investment  yields  a  substantial  reward,  but  there  are  fields  of  activity  where 
the  rewards  are  less  and  where  the  increased  cost  of  sanitation  fails  to  yield 
a  sufiicient  return.  The  law  of  diminishing  returns  has  its  application  in 
sanitation  as  well  as  in  economics.  It  is  only  by  careful  study  of  the  results 
of  sanitation  that  we  shall  be  able  to  properly  evaluate  the  different  sanitary 
measures  that  are  available  to  us,  and  it  is  in  this  direction  that  the  practical 
value  of  vital  statistics  lies.  More  and  more  is  the  science  of  demography 
playing  an  important  part  in  the  administration  of  public  health  and  it 
seems  certain  that  at  no  distant  future  the  science  of  demography  will  rank 
as  one  of  the  most  necessary  subjects  for  students  to  pursue  in  their  training 
for  the  public  health  service. 

It  is  recognized  also  that  the  realm  of  demography  cannot  be  confined  to 
the  statistics  of  marriages,  births,  and  deaths,  but  must  be  extended  to  include 
physiological  data  as  well  as  social  and  economic  statistics. 


51 


DIVISION  m 

Legislation  and  Governmental  Study  for  the  Prevention  of  Occu- 
pational Diseases 

CHAPTER  I 
METHODS  AND   SCOPE  OF  LEGISLATION 

BY  JOHN  B.  ANDREWS,  Ph.  D.,  New  York  City,  N.  Y. 

In  the  development  of  our  civilization  from  the  individualism  of  primitive 
savagery  to  the  complexity  of  modern  industrial  society,  we  have  created 
many  perplexing  social  problems.  When  individuals  worked  singly  and  in 
a  very  real  sense  "minded  their  own  business,"  it  was  possible  for  the  indi- 
vidual worker  to  adjust  himself  or  his  surroundings  to  suit  at  least  his  own 
best  judgment  concerning  personally  agreeable  and  healthful  conditions  of 
temperature,  humidity,  fresh  air  and  physical  strain.  But  when  factories 
were  built  and  large  numbers  of  people  came  to  work  under  artificial  condi- 
tions over  which  they  themselves  had  little  or  no  direct  control,  there  was 
created  a  very  different  problem.  Conditions  of  temperature  and  humidity 
and  purity  of  air  and  labor  strain  are  now  often  prescribed  by  the  most 
convenient,  the  most  rapid,  and  the  cheapest  process  of  manufacture  from 
the  standpoint  of  selfish  or  thoughtless  employers. 

Every  person  in  the  community  is  concerned  in  the  conservation  of  the 
health,  vitality,  energy,  and  industrial  efficiency  of  wage  earners.  All 
agencies  in  society  should  cooperate  in  preventing  unnecessary  suffering 
and  death  among  the  producing  classes.  The  protection  of  the  health  of 
the  industrial  worker  is  not  an  individual  question.  It  is  a  social  question 
demanding  social  regulation. 

The  prevention  of  occupational  diseases  is,  moreover,  too  great  an  under- 
taking to  be  left  entirely  to  individual  action.  It  cannot  be  left  to  the  worker 
who,  even  when  not  ignorant  of  the  danger,  is  driven  by  necessity  to  his  task. 
It  cannot  be  entrusted  to  the  employer  whose  principal  business,  after  all, 
under  competitive  conditions,  is  to  secure  profits.  It  cannot  be  left  to 
medical  treatment  alone,  for  prevention  and  not  after-care  is  the  remedy. 
Not  only  on  account  of  the  magnitude  of  the  problem,  but  also  because  of  its 
nature,  the  prevention  of  occupational  diseases  is  properly  a  function  of  govern- 
ment. Governmental  action,  however,  in  promoting  industrial  hygiene 
does  not  mean  that  private  or  voluntary  efforts  of  the  workmen,  or  of  their 
employers,  or  of  their  physicians  shall  be  in  any  way  minimized.  On  the 
contrary,  such  voluntary  efforts  will  be  vastly  encouraged. 

802 


METHODS   AND    SCOPE    OF   LEGISLATION  803 

It  must  be  obvious  to  any  thoughtful  person  that  in  preventing  un- 
necessary occupational  diseases  we  must  have  investigation,  education  and 
administration.  These  three  requisites  can,  in  a  democracy,  best  be  secured 
through  legislation. 

Investigation  is  expensive.  But  through  legislation  we  can  set  aside 
ample  funds  for  scientific  study.  In  New  York  state  during  the  2  years 
1912-1913  the  legislature  appropriated  $110,000  to  the  factory  investigating 
commission,  in  addition  to  the  usual  sustaining  funds  for  the  permanent 
departments  of  health  and  labor,  and  other  states  have  made  similar 
outlays. 

Education  is  expensive.  But  through  legislation  we  can  provide  the 
means  for  the  necessary  dissemination  of  facts  gained  by  investigation.  The 
reports  of  the  occupational  disease  commission  in  Illinois  and  of  the  factory 
investigating  commission  in  New  York,  as  well  as  the  splendid  researches  of 
several  governmental  commissions  in  England  and  elsewhere,  have  given  a 
remarkable  impetus  to  the  task  of  providing  sanitary  work  places.  Reports 
on  occupational  diseases  issued  by  our  bureaus  of  labor  have  stimulated  wide 
interest  among  manufacturers  and  wage  earners.  The  laws  in  16  states  and 
in  several  European  countries  requiring  the  reporting  of  occupational  diseases 
have  pointed  out  the  sore  spots  in  industry  and  have  resulted  in  valuable  co- 
operation between  physicians  and  factory  inspectors. 

Administration  is  essential.  Protective  devices  often  involve  the  ex- 
penditure of  large  sums  of  money  and,  under  conditions  of  sharp  competi- 
tion and  cheap  labor  in  an  industry,  the  humane  and  careful  employer  may 
be  placed  at  an  unfair  disadvantage  in  dealing  with  his  less  conscientious 
business  competitor  unless  there  is  uniform  enforcement  of  sanitary  regula- 
tions. It  is  only  through  uniformity  of  regulation,  which  legal  enact- 
ments alone  can  secure,  that  the  more  progressive  and  humane  employers 
can  themselves  be  protected  from  less  scrupulous  competitors  who  would 
otherwise  often  fail  to  provide  expensive  safeguards,  and  it  is  only  through 
compulsory  regulations  that  the  health  of  the  employees  of  these  unscrupulous 
competitors  can  be  protected.  A  notable  example  of  this  was  the  condition 
which  culminated  successfully  in  the  poisonous  phosphorus  prohibition  act 
described  in  an  earlier  section.  Match  manufacturers  representing  95  per 
cent,  of  the  total  product  testified  before  Congress  that  they  could  not 
substitute  a  harmless  compound  for  the  slightly  cheaper  poison  without  a 
uniform  law  compelling  all  employers  in  that  industry  to  abandon  the  poison. 
All  of  the  other  match  manufacturers,  however,  representing  the  remain- 
ing 5  per  cent,  of  the  product,  stood  out  stoutly  to  the  last,  even  declaring 
that  they  would  close  their  factories  before  they  would  submit  to  this  sani- 
tary measure,  already  in  compulsory  operation  in  practically  all  the  civilized 
countries  of  the  world.  It  required  labor  legislation  to  end  the  use  of  this 
unnecessary  deadly  poison  before  "phossy  jaw,"  the  most  loathsome  of  all 
industrial  diseases,  could  be  abolished. 


8o4  LEGISLATION    AND    GOVERNMENT    STUDY 

Three  Principal  Methods. — The  principal  legislative  remedies  for  the 
prevention  of  occupational  diseases  are  of  three  classes.     These  are: 

1.  The  method  of  prohibition. 

2.  The  method  of  regulation. 

3.  The  method  of  compensation  or  insurance. 

The  mass  of  legislation  which  falls  into  these  three  categories  is  con- 
stantly expanding  and  undergoing  amendment.  Any  study  of  it  is  further 
complicated  by  the  rapid  spread,  in  America  as  well  as  in  Europe,  of  the 
method  of  enforcement  by  administrative  order,  in  which  the  legislature  lays 
down  a  general  rule,  such  as  "  the  work  places  shall  be  safe,"  and  leaves  to  a 
commission  or  to  an  administrative  official  the  duty  of  making  the  necessary 
specific  regulations.  In  the  pages  which  follow  the  attempt  has  been  made  to 
present  only  the  broad  outstanding  principles  of  the  law.  Much  that  would 
be  essential  to  the  legislative  draftsman  has  been  omitted  in  the  hope  that, 
unencumbered  by  excessive  detail,  the  lay  reader  may  arrive  at  a  compre- 
hensive understanding  of  what  the  various  governments  are  doing  for  the 
abatement  of  occupational  diseases  among  their  wage-earning  population. 
Full  texts  of  the  European  laws  cited  may  be  found  in  the  files  of  the  monthly 
Bulletin  of  the  International  Labor  Office. 

I.  THE  METHOD  OF  PROHIBITION 

No  more  striking  example  of  the  method  of  prohibition  could  be  found 
than  the  suppression  of  white  phosphorus  in  the  match  industry.  As  has 
been  shown  elsewhere  in  this  volume,  every  leading  country  of  the  world 
has  now  outlawed  this  occupational  poison,  even  resorting  to  the  unique  ex- 
pedient of  forming  an  international  treaty  to  prohibit  an  occupational  disease. 

The  only  other  substance  against  which  such  drastic  action  has  been 
taken  in  industry  is  lead,  and  in  this  case  the  prohibitory  legislation  is  con- 
fined to  Europe.  Austria  was  first  to  act,  forbidding  in  1908  the  use  of  lead 
in  all  paints,  colors  or  cement  used  for  interior  work,  and  the  same  year  the 
various  Swiss  administrative  departments  were  ordered  to  prohibit  the  use 
of  white  lead  in  painting  carried  on  in  their  behalf.  In  1909,  however,  France 
took  the  most  advanced  stand  by  declaring  that  after  July  20,  1914,  the  use  of 
"white  lead,  of  linseed-oil  mixed  with  lead,  and  of  all  products  containing 
white  lead  will  be  forbidden  in  all  painting,  no  matter  of  what  nature,  carried 
on  by  working  painters  either  on  the  outside  or  in  the  inside  of  buildings." 
Whether  such  prohibition  is  to  spread  depends  largely  upon  the  success  of 
other  methods  in  combating  plumbism. 

Another  type  of  prohibitive  labor  legislation  is  directed  against  the  use  of 
dangerous  instruments.  Thus  in  textile  mills  the  extent  to  which  tuberculosis 
and  other  contagious  diseases  were  transmitted  by  the  workers'  sucking 
thread  into  the  shuttles  led  to  this  process  being  called  the  "kiss  of  death." 


METHODS    AND    SCOPE    OF    LEGISLATION  805 

In  191 1,  accordingly,  Massachusetts  forbade  the  use  of  any  form  of  shuttle 
which  requires  the  employee  to  use  his  lips  or  mouth  in  threading  it. 

2.  THE  METHOD  OF  REGULATION 

The  method  of  regulation,  in  the  prevention  of  occupational  diseases  as 
in  other  social  problems,  is  based  on  the  principle  of  toleration  within  limits. 
The  majority  of  the  people  may  beheve  that  certain  harmful  conditions  are 
so  necessary  a  part  of  our  industrial  life  that  their  prohibition  is  at  present 
undesirable  or  at  least  impracticable.  As  a  result,  the  method  of  regulation 
is  far  more  widely  used  than  the  method  of  prohibition,  as  well  as  being 
historically  much  older. 

The  adoption  of  this  method  leads  to  limitations  in  three  different 
directions:  (i)  upon  the  methods  of  handling  the  hazardous  material;  (2) 
upon  the  period  of  exposure;  and  (3)  upon  the  persons  exposed.  These  three 
types  of  limitation  are  seldom  used  singly,  but  are  usually  combined  in  the 
same  law.  In  the  following  discussion  no  attempt  will  be  made  to  describe 
the  laws  now  existing  in  most  industrial  states  and  countries  with  reference  to 
air-space,  ventilation,  general  dust  and  fume  removal,  temperature  regulation, 
toilet  facilities,  weekly  rest  days,  and  similar  general  matters,  because  while 
all  these  measures  have  a  bearing  on  the  health  of  the  operatives  they  are  not 
designed  as  protection  against  any  specific  occupational  illness.  No  mention 
will  be  made,  either,  of  provisions  applying  only  to  the  labor  of  women  and 
children,  as  such  provisions  are  treated  separately  elsewhere  in  this  volume. 

Lead. — The  most  widespread  of  industrial  poisons,  lead  is  also  most 
frequently  the  subject  of  regulative  laws.  Public  attention  was  first  called 
to  its  dangers  in  America  by  the  report  of  the  Illinois  Commission  on  Occu- 
pational Diseases  in  191 1,  since  which  date  six  states  have  enacted  specific 
protective  measures. 

The  most  advanced  of  these  measures,  prepared  by  the  American  Asso- 
ciation for  Labor  Legislation,  is  that  adopted  in  practically  identical  form 
by  the  Ohio  and  Pennsylvania  legislatures  in  1913,  and  in  New  Jersey  in 
1914.  Every  employer  is  required  to  provide,  without  cost  to  his  workmen, 
reasonably  effective  devices  to  prevent  illness  incident  to  the  processes  at 
which  they  are  engaged.  In  addition,  specific  regulations  are  made  to  pro- 
tect those  employed  in  the  manufacture  of  white  lead,  red  lead,  litharge, 
sugar  of  lead,  arsenate  of  lead,  lead  chromate,  lead  sulphate,  lead  nitrate  or 
fluo-silicate  and,  in  the  New  Jersey  law,  in  the  manufacture  of  pottery,  tiles, 
or  porcelain  enameled  sanitary  ware.  Workrooms  must  be  thoroughly 
lighted  and  ventilated.  Separate  rooms  must  be  provided  for  the  dusty  and 
therefore  more  dangerous  processes,  with  floors  which  can  be  cleaned  daily 
either  by  wet  methods  or  by  vacuum  cleaners.  Vessels  for  crushing,  drying 
or  conveying  the  lead  or  lead  salts  must  be  protected  by  hoods  or  dust  re- 
movers. Great  emphasis  is  laid  on  washing  facilities,  the  requirements  in- 
cluding hot  and  cold  water,  soap,  towels,  nail  brushes,  and  shower  baths; 


8o6  LEGISLATION   AND    GOVERNMENT    STUDY 

there  must  also  be  separate  dressing  rooms,  eating  rooms,  drinking  fountains, 
and  double  lockers,  and  respirators  must  be  furnished.  At  least  lo  minutes 
on  the  employer's  time  must  be  allowed  each  employee  before  lunch  and  at 
closing  for  the  use  of  the  wash  room,  and  an  additional  lo  minutes  twice 
a  week  for  the  use  of  the  shower  baths.  The  employees  are  made  subject 
to  fine  in  case  of  failure  to  use  the  facilities  for  cleanliness  which  are  pro- 
vided, and  are  not  to  take  any  food  or  drink  into  the  workrooms.  Every  em- 
ployee exposed  to  danger  from  lead  dust  or  fume  must  be  examined  medically 
at  least  once  a  month  by  a  physician  paid  by  the  employer.  If  lead  poison- 
ing symptoms  are  found,  a  record  must  be  filed  with  the  factory  inspection 
department  within  48  hours  and  a  copy  sent  to  the  employer,  who  may  not 
thereafter  employ  that  worker  in  any  place  exposing  him  to  lead  without  a 
written  permit  from  a  physician.  Notices  in  English  and  in  such  other 
languages  as  the  circumstances  require  must  be  prominently  posted,  stating 
the  dangers  and  giving  instructions  for  avoiding  them. 

The  Missouri  law,  also  of  1913,  and  the  Illinois  act  of  1911  contain  very 
nearly  the  same  provisions  with  respect  to  washing  and  lunch-room  facilities, 
dust  removal,  and  medical  examination  of  employees.  They  lack,  however, 
the  clause  imposing  hygienic  duties  on  the  workers  as  well  as  on  the  em- 
ployers. Both  these  laws,  also,  differ  from  that  just  described  by  being  less 
specific  but  more  inclusive.  The  Illinois  act  of  191 1  applies,  in  addition  to 
occupations  involving  contact  with  the  familiar  poisonous  lead  salts,  to  brass 
manufacture  and  to  lead  and  zinc  smelting,  while  the  Missouri  statute  aims 
to  cover  any  process  "in  which  antimony,  arsenic,  brass,  copper,  lead, 
mercury,  phosphorus,  zinc,  their  alloys  or  salts,  or  any  poisonous  chemicals, 
minerals,  acids,  fumes,  vapors,  gases  or  other  substances  are  generated  or 
used  in  harmful  quantities  or  under  harmful  conditions." 

The  New  York  law,  enacted  in  191 2,  merely  forbids  the  taking  of  food 
into  any  workroom  where  lead,  arsenic  or  other  poisonous  substances  are 
present,  and  requires  the  maintenance  of  a  separate  lunch  room. 

In  Europe  the  tendency  is  away  from  such  omnibus  legislation  and 
toward  minute  regulation  for  each  of  the  important  lead  industries  separately. 
This  tendency  is  perhaps  best  exhibited  in  Germany,  which  country  not 
only  was  one  of  the  first  to  establish  scientific  standards  for  the  lead-using 
trades,  but  has  to-day  the  greatest  mass  of  legislation  bearing  on  the  subject. 
Separate  statutes  exist  for  lead  mining,  casting,  zinc  smelting,  type  founding 
and  stereotyping,  typesetting,  white  lead  manufacturing,  lead  oxides  and 
paints,  electric  accumulators,  painting  and  file  cutting.  England  has 
passed  separate  laws  or  issued  separate  administrative  orders  governing  lead 
smelting  and  casting,  lead  founding,  white  lead,  lead  oxides  and  paints, 
electric  accumulators  and  file  cutting,  heading  yarn  dyed  with  a  lead  com- 
pound, earthenware  and  china,  color  transfers  on  earthenware  and  china, 
and  tinning  and  enameling.  In  Austria,  France  and  Belgium  similar  but 
shorter  lists  of  industries  have  been  individually  regulated. 


METHODS   AND    SCOPE    OF    LEGISLATION  807 

In  the  more  dangerous  trades  in  the  countries  named,  the  workers  are 
forbidden  to  eat  or  to  leave  the  premises  where  they  are  employed  until  they 
have  first  thoroughly  washed  their  hands  and  their  faces  and  in  some  cases 
their  mouths  and  noses  also.  No  food  or  beverage  of  any  kind,  and  no  tobacco 
either  for  smoking,  chewing,  or  snuffing,  may  be  used  in  or  even  carried  into 
the  workroom.  In  the  more  dusty  trades,  such  as  white  lead  making,  lead 
oxidizing  and  electric  accumulator  manufacture,  the  men  must  take  warm 
baths  regularly,  in  some  cases  weekly  and  in  some  cases  daily.  In  the 
white  lead  industry  in  England  a  register  must  be  kept  of  these  baths. 

Much  emphasis  is  thrown  on  adequate  ventilation  and  lighting.  The 
walls  and  floors  of  the  chambers  where  dusty  processes  are  carried  on  must  be 
hard  and  impervious,  and  must  be  cleaned  by  moist  methods  or  with  a 
hose  at  regular  intervals.  Mechanical,  hooded  contrivances  for  crushing, 
mixing  and  transporting  dangerous  lead  products  are  generally  specified  in 
the  law.  The  employer  must  furnish  working  clothing,  gloves,  respirators, 
and  sometimes  head  coverings,  and  lockers  in  which  to  keep  them.  There 
must  be  dressing  rooms,  and  wash  rooms  supplied  with  hot  and  cold  water, 
soap,  towels,  nail  brushes,  and  bathing  facilities;  a  dust-free  room,  warmed  in 
cold  weather  and  in  some  cases  provided  with  means  for  warming  the 
workmen's  food,  must  be  set  aside  as  a  lunch  room.  In  some  of  the  more 
arduous  trades  the  hours  are  made  short  and  are  broken  by  frequent  rest 
pauses.  Notices  of  the  law  must  be  posted,  and  sometimes  must  also  be 
distributed  to  the  employees. 

Germany  in  the  lead  smelting,  white  lead,  lead  oxide,  storage  battery 
and  painting  trades,  England  in  all  but  the  last  of  these,  with  the  addition  of 
yarn  heading  and  earthenware,  and  Austria  in  lead  and  zinc  smelting  re- 
quire a  ''control  book"  or  health  register.  The  German  book  is  a  very 
elaborate  affair,  requiring  records  of  the  name  of  the  person  keeping  it,  first 
and  last  name,  address  and  age  of  each  workman,  date  of  his  entering  and 
leaving  the  employment,  date  and  nature  of  his  illness,  date  of  his  recovery, 
name  of  the  factory  physician,  and  dates  and  results  of  the  medical  examina- 
tions. The  employer  is  responsible  for  the  correctness  of  this  record  and 
must  show  it  to  the  factory  or  medical  inspector  on  demand.  The  Austrian 
health  register  goes  into  even  more  detail. 

Before  a  workman  in  Germany,  England,  France,  Austria,  or  Russia  can 
legally  obtain  work  in  the  dangerous  lead  trades,  he  must  provide  himself  with 
a  medical  certificate  showing  that  he  is  of  sound  physique  and  constitution 
and  fairly  capable  of  withstanding  the  poisons  with  which  he  will  have  to 
work.  Lung,  kidney  or  stomach  trouble,  alcoholism  and  a  generally  weak 
constitution  are  debarring  ailments  in  Germany.  The  French  law  excludes 
workers  who  exhibit  symptoms  of  lead  poisoning  or  of  any  complaint  likely 
to  be  dangerously  aggravated  by  plumbism.  In  Belgium  no  workman 
addicted  to  alcohol  may  be  employed  in  white  lead,  lead  oxide  or  lead  paint 
making. 


8o8  LEGISLATION    AND    GOVERNMENT    STUDY 

Having  secured  employment  in  a  lead  trade,  the  workman's  continuation 
therein  is  usually  dependent  on  his  successfully  resisting  its  inherent  hazards. 
The  frequency  of  compulsory  medical  examination  ranges  from  i  every  6 
months  for  painters  in  Germany  to  i  a  week  in  the  Enghsh  white  lead 
industry.  In  most  cases,  however,  i  examination  a  month  is  the  re- 
quirement; in  white  lead  and  lead  oxides  in  Germany  it  is  2  a  month. 
When  a  worker  is  discovered  to  have  symptoms  of  plumbism,  the  laws  almost 
universally  require  that  he  be  "suspended,"  that  is,  given  employment  which 
keeps  him  out  of  contact  with  lead  until  he  has  fully  recovered.  Belgium, 
in  the  white  lead  industry,  requires  that  a  leaded  man  be  kept  out  of  that 
sort  of  work  permanently. 

A  decisive  clause  found  repeatedly  in  the  German  laws,  and  also  in  the 
Austrian  statute  on  lead  and  zinc  smelting,  is  that  a  workman  continually 
violating,  after  warning,  the  hygienic  duties  laid  upon  him  is  to  be  perma- 
nently discharged  without  notice.  A  similar  but  much  weaker  clause  is  the 
provision  occasionally  found  in  England  that  a  reckless  worker  lays  himself 
open  upon  conviction  to  a  fine. 

Several  countries  have  turned  their  attention  to  house  painting,  a  pro- 
lific source  of  painful  and  annoying  but  less  often  fatal  attacks  of  plumbism. 
France,  Germany  and  Belgium  forbid  all  rubbing  or  scraping  of  lead  paint 
in  a  dry  state.  In  France  the  manipulation  with  the  bare  hands  of  any 
material  containing  white  lead  is  also  forbidden.  Belgium  in  1909  decided 
that  white  lead  for  painting  could  be  transported,  sold  or  used  only  in  the 
form  of  a  paste  or  liquid  mixed  with  oil.  The  ministry  was  given  power  to 
extend  the  same  restriction  to  white  lead  for  any  other  purpose,  but  later  the 
law  was  weakened  to  allow  special  permits  to  persons  who  could  prove  the 
necessity  of  their  using  white  lead  in  powder  or  cakes.  A  mild  ministerial 
order  is  found  in  Austria,  where  it  is  allowable  to  import  or  sell  lead  colors  or 
cement  only  if  the  fact  that  they  contain  lead  is  "expressly  marked  upon 
them  in  a  clear  and  comprehensible  manner." 

Brass. — ^Legislative  provision  is  made  for  the  control  of  brass  fume  and 
dust  under  the  Illinois  and  Missouri  lead  laws  already  mentioned,  but 
nowhere  else  specifically  in  this  country.  In  England  exhaust  drafts  for  the 
prompt  removal  of  fumes,  and  arrangements  for  preventing  the  fumes  from 
spreading  to  other  rooms,  must  be  provided.  For  the  personal  care  of 
the  employees,  also,  there  must  be  washing  accommodations,  with  soap, 
nail  brushes  and  towels. 

Miscellaneous  Dusts. — Three  states — Illinois,  Michigan  and  New  Jersey 
— have  detailed  legislation  looking  toward  the  removal  of  the  miscellaneous 
dusts  generated  in  the  grinding  and  polishing  rooms  of  many  industrial  es- 
tablishments. These  laws  designate  the  kind  of  machines  covered  by  the 
act,  how  the  protective  devices  shall  be  adjusted  to  the  machines,  the  dimen- 
sions of  the  connecting  pipes,  and  the  degree  of  the  angles  as  well  as  the  rate 
of  speed  at  which  the  fans  or  blowers  shall  run.     In  addition,  about  half 


METHODS    AND    SCOPE    OF    LEGISLATION 


809 


the  states  in  the  union  have  enacted  more  general  laws  on  the  same  topic. 
Fairly  representative  of  this  type  of  legislation  is  the  Oregon  statute  of  1907, 
providing  that  "if  in  any  factory,  mill  or  workshop  any  process  is  carried 
on  in  any  enclosed  room  thereof,  by  which  dust  is  generated  and  inhaled 
to  an  injurious  degree  by  the  persons  employed  therein,  conveyors,  receptacles 
or  exhaust  fans,  or  other  mechanical  means,  shall  be  provided  and  main- 
tained for  the  purpose  of  carrying  off  and  receiving  such  dust."  As  scientific 
standards  of  dust  control  and  removal  are  developed,  and  inspectors  become 
technical  experts  and  advisers  instead  of  mere  detectives,  such  laws  can 
be  made  more  and  more  useful  agencies  in  factory  hygiene. 

Similar  general  legislation,  directed  mainly  toward  the  protection  of 
metal  polishers,  exists  in  a  number  of  European  countries,  among  them  being 
Holland,  Italy,  and  Norway. 

Compressed  Air. — Another  important  source  of  industrial  illness  and 
death  which  has  been  brought  under  legislative  regulation  in  America  is 
work  in  compressed  air.  The  earliest  American  statute  designed  to  combat 
this  hazard  is  the  New  York  act  of  1909,  which  has  twice  been  strengthened 
by  amendment  and  is  now  much  excelled  by  the  New  Jersey  law  of  1914. 

The  New  Jersey  law  requires  a  medical  examination  of  all  persons  apply- 
ing for  employment  in  caissons  or  tunnels  where  work  in  abnormal  air  pres- 
sure is  carried  on.  Only  those  found  physically  qualified  may  be  employed, 
and  persons  addicted  to  the  excessive  use  of  intoxicants  are  expressly  debarred. 
Examinations  must  be  repeated  on  returning  to  work  after  10  days'  absence 
and  after  3  months'  continuous  employment,  and  records  must  be  kept  of 
all  examinations. 

Working  periods  and  rest  intervals  are  carefully  regulated  in  accordance 
with  the  following  scale,  in  which  "pounds"  refers  to  pressure  in  addition 
to  the  normal  atmospheric  pressure  of  15  lb.  to  the  square  inch.  No  work 
is  allowed  in  pressure  over  50  lb.  except  in  cases  of  emergency. 


If  the  pressure  exceeds, 
pounds 

But  does  not  exceed, 
pounds 

Number  of  hours 
work  in  24,  hours 

Interval  between  work- 
ing periods,  hours 

Normal 

21 

8 

1 

Yt. 

21 

30 

6 

I 

30 

35 

4 

2 

35 

40 

3 

3 

40 
45 

45 

50 

2 

4 
5 

As  too  rapid  emergence  from  high  pressure  is  the  main  cause  of  caisson 
disease,  a  decompression  lock  is  required,  through  which  the  workman  must 
pass  as  he  leaves  the  work,  and  the  speed  of  decompression  is  held  within  safe 
limits.  In  tunnels  decompression  may  be  at  the  rate  of  3  lb.  every  2  minutes, 
unless  the  pressure  is  over  36  lbs.,  when  it  may  be  only  i  lb.  a  minute.  In 
caissons  a  more  rapid  rate  is  permitted,  to  wit: 


8io 


LEGISLATION   AND    GOVERNMENT    STUDY 


If  the  pressure  exceeds, 
pounds 

But  does  not  exceed, 
pounds 

Time  required  for  compression, 
minutes 

Normal 

10 

I 

lO 

IS 

2 

15 

20 

5 

20 

25 

10 

25 

30 

12 

30 

36 

IS 

36 

40 

20 

40 

50 

25 

Dressing  rooms  with  hot  and  cold  shower  baths  must  be  kept  open  during 
and  between  working  periods,  and  also  a  separate  room  for  drying  clothes. 
If  the  pressure  exceeds  17  lb.  a  double  medical  lock  is  required,  in  which 
sufferers  from  "the  bends"  may  be  placed  for  recompression  and  treatment, 
and  which  must  be  equipped  with  inside  and  outside  air  gauges,  time  pieces 
and  a  telephone.  All  equipment  must  be  inspected  every  day.  One  or  more 
licensed  physicians  must  be  present  at  all  necessary  times,  and  if  the  pressure 
exceeds  17  lb.  the  constant  attendance  of  registered  nurses  or  of  other  compe- 
tent persons  certified  by  the  medical  officer  is  also  required. 

France  and  Holland  have  also  legislated  concerning  compressed-air 
work.  The  French  law  requires  from  applicants  medical  certificates  of 
fitness,  which  are  to  be  renewed  2  weeks  later  and  subsequently  every  month, 
and  establishes  minute  regulations  governing  safety  appliances,  medical  locks, 
and  time  of  decompression.  In  Holland  the  supervising  physician  is  ap- 
pointed and  paid  by  the  government,  and  must  give  the  workmen  necessary 
instructions  with  regard  to  health.  A  long  list  of  ailments  is  included  in  the 
law,  any  of  which  debar  from  work  in  compressed  air.  These  ailments 
are  malformation,  imperfect  physical  development,  general  debility,  obesity, 
chronic  diseases  of  the  skin,  inflamed  or  swollen  glands,  boils  or  abscesses 
which  may  be  expected  to  cause  trouble,  excessive  perspiration  of  the  feet, 
chronic  affections  of  the  bones  or  of  the  muscular  system  or  joints,  diseases 
of  the  heart  or  of  the  nervous  system  or  the  blood,  affections  of  the  trachea  or 
lungs,  chronic  affections  of  the  digestive  organs,  rupture,  diseases  of  the 
kidneys  or  bladder,  gonorrhea,  suspected  alcoholism  and  affections  of  the 
nose  and  ears. 

The  use  of  the  diving  dress  jn  sponge  fishing  has  been  prohibited  in 
Austria-Hungary,  Crete,  Egypt,  and  Samos,  while  both  Greece  and  Italy 
have  placed  restrictions  on  the  depth  to  which  divers  may  go,  the  Grecian 
limit  being  127  ft. 

Textile  Dust. — Specific  regulations  against  dust  and  lint  in  textile 
establishments  have  for  some  years  been  established  in  England.  In  the 
dusty  rooms  exhausts  and  respirators  are  required,  as  well  as  thermometers 
and  hygrometers  for  the  regulation  of  temperature  and  humidity.  The  law 
provides  also  for  the  purity  of  the  water  used  for  humidifying.     These  regula- 


METHODS   AND    SCOPE    OF    LEGISLATION  8ll 

tions  apply  to  the  spinning  and  weaving  of  flax,  tow,  hemp  and  jute.  In 
Massachusetts  a  1910  law  safeguards  the  purity  of  the  water  used  in  humidify- 
ing weaving  and  spinning  rooms,  and  standardizes  the  thermometers  for 
regulating  temperature. 

Rag  Dust. — An  Austrian  law  aims  to  protect  workers  in  paper  mills  from 
the  irritating  and  infectious  dust  often  carried  by  old  rags.  Tearing  and 
dusting  of  the  rags  must  be  done  mechanically.  Washing,  bathing  and 
dressing  accommodations,  working  clothes,  respirators  and  first-aid  materials 
are  required,  and  eating  and  smoking  are  prohibited  in  the  workrooms.  Per- 
sons with  delicate  respiratory  organs,  consumptives,  and  workers  with  open 
wounds  may  not  be  employed. 

Stone  Dust. — To  guard  the  workers  in  stone  quarries  and  stone-dressing 
establishments  from  the  dangerous  dust  created,  Germany  requires  that  the 
floors  shall  be  kept  damp,  and  workmen  may  not  sit  closer  together  than  2 
meters  (about  63^^  ft.).  Roof  shelters  must  be  erected  to  protect  the  workers 
from  the  weather;  men  may  work  at  dressing  sandstone  only  9  hours  a  day, 
and  at  other  occupations  10  hours.  In  Austria  quarrymen  must  be  pro- 
vided with  goggles  or  eye  shades.  The  regulations  in  Holland  are  more 
thorough.  Hours  are  limited  to  10  a  day  for  the  first  2  years  and  9  there- 
after, precautions  must  be  taken  against  the  formation  and  spread  of  dust, 
and  workmen  are  entitled  to  medical  examination  once  a  year. 

Chromates. — ^Provisions  for  the  prevention  of  chrome  ulceration  and  other 
diseases  caused  by  contact  with  chromates  are  found  in  Austria,  Germany 
and  England.  The  German  rules  are  that  dust-producing  processes  must  be 
carried  on  away  from  the  general  workrooms,  and  the  chromates  must  as  far 
as  possible  be  crushed  in  hermetically  sealed  apparatus.  Working  clothes, 
caps  and  respirators  are  required  for  the  employees,  together  with  warm 
baths,  soap,  towels  and  nail  brushes,  cloak  rooms  and  lunch  rooms.  For 
employment  a  certificate  is  necessary,  stating  that  the  applicant  has  no  open 
wounds  or  skin  disease.  Monthly  medical  examinations  are  required,  and 
workmen  showing  symptoms  of  chrome  poisoning  in  the  form  of  irritation 
of  the  mucous  membrane  of  the  nose  must  be  suspended. 

The  English  regulations  covering  the  manufacture  of  chromates  of  sodium 
are  almost  identical  with  the  German.  A  notable  addition  is  that  foremen 
must  report  to  their  managers  the  names  of  workmen  who  fail  to  observe  the 
rules  for  personal  hygiene. 

Bisulphide  of  Carbon. — In  rooms  where  bisulphide  of  carbon  is  used  in 
vulcanizing  rubber,  England  forbids  work  for  longer  than  5  hours  a  day,  and 
no  food  may  be  eaten  there.  Employees  must  be  examined  monthly,  and 
records  kept  of  the  examinations. 

More  detailed  precautions  against  the  same  poison  are  established  in 
Germany.  Provision  is  made  for  special  ventilators,  devices  to  prevent  the 
escape  of  the  fumes,  cloak  rooms  and  washing  accommodations  with  soap 
and  towels.     Monthly  medical  examinations  are  required. 


8l2  LEGISLATION    AND    GOVERNMENT    STUDY 

Mercury.— In  animal  hair-cutting  establishments  where  mercury  is  used, 
France  requires  the  posting  of  the  following  notice: 

^'otice.— 'Mercury  and  its  compounds  are  dangerous.  They  may  enter  the  body  with 
the  air  breathed  in  (dust,  vapors),  with  food  (unclean  hands,  unclean  tables),  through 
the  skin  (cracks,  scratches,  or  cuts). 

Should  you  have  any  cracks,  scratches  or  cuts  please  inform  the  management 
immediately  of  the  fact. 

Before  eating  or  drinking  carefully  clean  your  hands  with  soap  and  your  mouth  with 
drinking  water. 

Should  you  have  any  pains  in  the  mouth  or  teeth  and  excessive  quantity  of  saliva, 
should  you  shiver,  should  you  have  swellings  of  the  legs,  the  hands,  or  under  the  eyes, 
consult  the  doctor  at  once. 

Tobacco. — Injurious  quantities  of  tobacco  dust  are  carefully  guarded 
against  in  Germany.  The  floors,  ceiling,  height  of  walls,  windows  and  air- 
space of  rooms  where  tobacco  is  worked  up  are  regulated.  The  tobacco  must 
be  kept  moist,  and  only  enough  for  i  day's  work  may  be  stored  in  the  work- 
room, which  must  be  aired  three  times  a  day  and  thoroughly  cleaned  twice 
a  year.  The  dust  must  be  removed  from  floors  and  tables  daily  by  washing 
or  by  damp  duster,  and  spittoons  and  lavatory  accommodations  with  soap 
and  towels  must  be  provided.  Spitting  on  the  floor  is  prohibited,  the  mouth 
must  not  be  used  in  making  cigars,  nor  may  the  cigar  knife  be  moistened 
with  saliva.  A  worker  who  violates  the  rules  after  repeated  warning  is 
to  be  discharged  without  notice. 

Anthrax. — Of  the  infectious  diseases  which  have  gained  occupational 
prominence,  anthrax — described  in  detail  in  an  earlier  chapter — has  most 
widely  been  made  the  subject  of  preventive  legislation  Austria,  Belgium, 
France,  Germany,  some  of  the  German  kingdoms,  Great  Britain  and 
Italy  have  all  turned  their  attention  to  stamping  out  the  disease;  the  United 
States  still  lags  behind. 

In  1 901  Great  Britain  ordered  that  provision  be  made  for  keeping  the 
workers'  food  and  clothing  in  a  clean  place.  Water,  soap,  towels  and  nail 
brushes  are  to  be  furnished,  and  all  requisites  for  treating  scratches  and 
slight  wounds  must  be  at  hand.  If  dangerous  hides  are  handled,  overalls 
protecting  the  neck  and  arms,  and  gloves,  are  required.  It  is  the  duty  of 
every  workman  having  an  open  cut  to  report  the  fact  immediately  to  the 
foreman  and  to  withdraw  from  the  shop  until  the  cut  is  healed.  Still  more 
careful  regulations  were  later  prescribed  for  work  on  horsehair  from  China, 
Siberia  or  Russia,  and  on  wool,  goat  and  camel  hair.  In  addition  to  the  fore- 
going requirements,  material  which  has  not  been  disinfected  must  be  kept  in 
a  separate  room  to  which  no  food,  drink  or  tobacco  may  be  taken,  and  no 
work  except  opening  and  sorting  may  be  done  upon  it  before  disinfection. 
In  addition  to  overalls  and  head  coverings,  the  work-people  must  be  pro- 
vided with  respirators. 

The  German  rules  for  disinfection  and  for  sanitation  of  the  work  place  are 


METHODS    AND    SCOPE    OF    LEGISLATION  813 

more  strict,  but  otherwise  the  regulations  follow  very  closely  those  of  Eng- 
land. An  administrative  order  in  France,  dated  October  i,  1913,  compiles 
and  amplifies  several  earlier  rules.  Three  notable  requirements  are  the 
appointment  of  a  factory  physician  for  the  examination,  treatment  and 
recording  of  cases,  a  first-aid  box,  and  lime- washing  of  the  workrooms 
"whenever  necessary,  and  especially  when  a  case  of  anthrax  has  occurred." 

Belgium  first  turned  its  attention  to  the  prevention  of  anthrax  among 
"longshoremen,  forbidding  in  1903  their  direct  touching  of  skins,  horns,  bristles 
or  other  material  capable  of  conveying  the  infection,  and  dock  workers  with 
wounds  on  exposed  parts  of  the  body  were  required  to  bandage  the  wounds 
before  handling  such  material.  Five  years  later  managers  of  brush  factories 
were  ordered  to  subject  all  bristles,  immediately  upon  unpacking,  to  a  system 
of  disinfection  capable  of  destroying  anthrax  spores.  Austria  in  1913  en- 
acted the  sweeping  provision  that  on  the  appearance  of  any  one  of  a  number 
of  contagious  diseases,  anthrax  among  them,  a  plant  might  be  ordered  closed 
if  its  operation  entailed  urgent  danger  to  the  population.  Italy  has  as  yet 
gone  no  further  than  offering  a  prize  for  the  best  essay  on  anthrax  prevention. 

Ankylostomiasis. — As  the  infection  of  miners  with  ankylostomiasis,  or 
"miners'  hookworm,"  takes  place  mainly  through  soil  pollution  by  others 
already  suffering  from  the  parasite,  a  few  countries  have  taken  precautions 
to  prevent  persons  with  the  disease  from  securing  employment  in  mines. 
In  1904  the  Austrian  Minister  of  Agriculture  issued  a  circular  to  the  mine 
inspectors  in  the  districts  of  Vienna,  Klagenfurt  and  Kracow  prescribing  the 
examination  of  applicants  with  this  end  in  view.  Similar  laws  exist  in  the 
Dortmund  district  of  Prussia  and  in  the  kingdom  of  Saxony,  while  a  royal 
order  prescribing  this  and  other  hygienic  precautions  was  issued  in  Spain 
in  1912. 

Contagious  Diseases  among  Glass-blowers. — While  many  industrial 
conditions  predispose  to  tuberculosis,  in  no  case  is  the  occupational  causation 
of  this  disease  clearer  than  when  it  occurs  among  glass-blowers.  A  French 
law  requires  the  appointment  of  a  physician  for  the  medical  supervision  of 
employees  in  glass  works,  and  the  keeping  of  a  health  register.  The  same 
law  contains  the  rather  weak  provision  that  "workers  shall  not  be  allowed  to 
undertake  any  work  necessitating  the  common  use  of  one  blowpipe,  except 
only  by  the  written  certificate  of  the  medical  man  to  the  effect  that  they  are 
not  suffering  from  any  contagious  disease  at  a  stage  in  which  such  illness  is 
capable  of  being  transmitted  by  the  blowpipe."  An  earlier  law  in  Portugal 
makes  the  prohibition  complete.  It  says:  "As  good  ground  exists  for  sup- 
posing that  the  prevalence  of  tuberculosis  in  glass-blowing  works  is  largely 
caused  by  permitting  free  use  of  the  same  blowpipe  by  different  workmen, 
his  majesty  the  king  hereby  commands  that  every  workman  shall  be  pro- 
vided with  a  blowpipe  for  his  personal  use,  marked  with  his  name  or  number, 
and  that  the  use  of  such  blowpipe  by  other  workmen  shall  be  absolutely 
forbidden." 


8 14  LEGISLATION   AND    GOVERNMENT   STUDY 

3.  THE  METHOD  OF  COMPENSATION  OR  INSURANCE 

The  third  and  last  of  the  principal  legislative  remedies  for  the  prevention 
of  occupational  diseases  is  the  method  of  compensation  or  insurance.  While 
newer  than  the  other  two  methods,  its  results  are  already  by  no  means 
inconsiderable. 

The  method  of  compensation  or  insurance  is  based  on  the  principle  that 
those  individual  misfortunes  which  cannot  be  prevented,  either  by  prohibition 
or  regulation,  can  best  be  borne  by  the  community.  When  applied  to  in- 
dustrial injuries  sustained  by  workmen  in  the  course  of  their  employment, 
the  justification  for  this  principle  is  particularly  obvious.  It  is  worthy  of 
note  also  that  with  almost  startling  rapidity  the  American  people  are  coming 
to  demand  that  workingmen's  insurance  be  recognized  as  a  proper  function 
of  government. 

The  expense  of  broken  machines  is  borne  by  the  industry,  which  passes  the 
burden  on  to  society.  In  recent  years  we  have  come  to  insist  that  so,  also, 
should  be  borne  the  financial  expense  of  broken  legs  and  arms.  The  next 
step  must  be  the  extension  of  the  same  principle  to  include  incapacity  due  to 
arms  paralyzed  by  lead  poisoning  or  incapacity  due  to  other  diseases  of  occu- 
pation. Instead  of  leaving  the  money  loss,  as  well  as  the  physical  suffering, 
to  be  borne  by  the  unfortunate  victim  or  his  family,  the  financial  burden  of 
relief  should  be  placed  upon  industry  where  it  belongs. 

During  the  past  few  years  the  industrial  accident  problem,  under  the 
urge  of  impending  legislation,  has  attracted  the  abilities  of  hundreds  of  ex- 
perts. In  addition  to  stringent  regulations  for  the  direct  prevention  of  such 
industrial  injuries,  33  states,  in  their  efforts  to  provide  adequate  relief  for  the 
victims,  have  boldly  overthrown  the  discredited  and  out-worn  system  of  em- 
ployers' liability  and  have  adopted  the  workmen's  compensation  or  insurance 
principle.  No  agitation  has  been  more  effective  in  preventing  accidents 
than  the  campaign  to  provide  for  the  victims  a  just  system  of  indemnity. 

And  in  attempting  to  deal  effectively  with  the  occupational  disease  prob- 
lem, practical  people  will  very  soon  recognize  the  wisdom  of  placing  upon 
those  responsible  for  unhealthful  work  conditions  the  financial  burden  of 
caring  for  the  victims.  No  intelligent  person  can  go  far  in  the  study  of  com- 
pensation for  industrial  accidents  without  realizing  that  a  logical  considera- 
tion of  the  facts  must  lead  likewise  to  compensation  for  industrial  diseases. 
In  fact  the  arguments  used  so  effectively  by  advocates  of  compensation  for 
accidents,  and  now  so  generally  accepted  by  all  men,  apply  with  even  greater 
force  in  the  consideration  of  relief  for  the  victims  of  occupational  diseases. 
A  considerable  part  of  the  money  now  paid  to  employers'  liability  companies 
and  to  ambulance  chasers  could,  under  a  just  system  of  compensation,  go 
where  it  belongs — to  the  injured  workman  or  his  family.  Expensive,  annoy- 
ing, and  unsatisfactory  litigation  could  be  reduced  to  a  minimum.  Infor- 
mation concerning  special  danger  points  in  industry  would  be  automatically 
pointed  out  to  the  factory  inspectors  in  a  manner  both  prompt  and  sure. 


METHODS   AND    SCOPE    OF    LEGISLATION 


815 


Unnecessary  occupational  diseases  would  then  be  prevented,  and  that  is  the 
real  problem. 

While  a  few  large  awards  have  been  made  under  liability  lawS;  American 
victims  of  occupational  diseases  are  still,  except  in  California  and  Massa- 
chusetts, practically  without  relief.  In  the  latter  state,  beginning  in  1914, 
the  supreme  court  has  several  times  upheld  awards  by  the  industrial  acci- 
dent board  on  the  ground  that  the  occupational  diseases  compensated  were 
"personal  injuries"  within  the  meaning  of  the  act.  The  California  legis- 
lature in  191 5  brought  occupational  diseases  within  the  scope  of  her  com- 
pensation law  of  191 1  by  striking  out  the  word  "accidental"  as  applied  to 
compensable  personal  injuries. 

The  United  States  government,  since  1908,  has  had  an  accident  compensa- 
tion law  applying  to  certain  civilian  employees.  But  victims  of  occupational 
disease  in  the  service  of  the  country  are  excluded  from  its  benefits.  In  1913 
the  Department  of  Commerce  published  a  report  upon  the  operation  of  this 
law.  Sixty-six  closely  printed  pages  are  devoted  to  embarrassing  questions 
arising  out  of  occupational  diseases  contracted  in  the  government  service. 
One  of  the  most  urgent  recommendations  for  a  change  in  the  law  is  that  it 
be  extended  specifically  to  embrace  diseases  of  occupation,  and  a  carefully 
drafted  bill  for  that  purpose  has  been  introduced  into  Congress  at  the 
instance  of  the  Association  for  Labor  Legislation.  When  this  measure  is 
enacted,  the  United  States  will  have  a  compensation  law  which  is  abreast 
of  those  of  the  most  progressive  nations  of  the  world. 

Great  Britain. — The  country  which  led  and  still  leads  in  the  matter  of 
compensation  for  occupational  diseases  is  Great  Britain.  Its  workmen's  com- 
pensation act  of  1906  contained  a  pioneer  schedule  of  six  diseases  for  which 
compensation  was  to  be  paid  on  the  same  basis  as  for  accidents.  This  list  has 
twice  been  extended  until  to-day  no  fewer  than  25  maladies  of  occupation 
entitle  the  victims  to  relief.     So  important  is  this  Hst  that  it  is  given  in  full: 

OCCXIPATIONAL  DISEASES  StJBJECT  TO  COMPENSATION  UNDER  THE  BeITISH  WoRKMEN'S 

Compensation  Act 
Diseases  Listed  in  Original  Act,  December  21,  1906 


Description  of  disease 


Description  of  process 


Anthrax. 

Handling  of  wool,  hair,  bristles,  hides  and 

skins. 

Lead  poisoning  or  its  sequelae. 

Any  process  involving  the  use  of  lead  or  its 

preparations  or  compounds. 

Mercury  poisoning  or  its  sequelae. 

Any  process  involving  the  use  of  mercury  or 

its  preparations  or  compounds. 

Phosphorus  poisoning  or  its  sequelae. 

Any  process  involving  the  use  of  phosphorus 

or  its  preparations  or  compounds. 

Arsenic  poisoning  or  its  sequelae. 

Any  process  involving  the  use  of  arsenic  or 

its  preparations  or  compounds. 

Ankylostomiasis. 

Mining. 

8i6 


LEGISLATION    AND    GOVERNMENT    STUDY 


Diseases  Added  by  Order  or  Secretary  of  State,  May  22,  1907,  December  2,  ic 

AND  July  30,  1913 


Description  of  disease  or  injury 


1.  Poisoning   by  nitro  and  amido  deriva- 

tives of  benzene  (dinitrobenzol,  aniline, 
and  others),  or  its  sequelas. 

2.  Poisoning  by  carbon  bisulphide  or  its 

sequelae. 

3.  Poisoning    b}^    nitrous    fumes    or    its 

sequelae. 

4.  Poisoning    by    nickel    carbonyl    or    its 

sequelae. 

5.  Arsenic  poisoning  or  its  sequelae. 

6.  Lead  poisoning  or  its  sequelae. 

7.  Poisoning  by  Gonioma  Kamassi  (African 

boxwood)  or  its  sequelae. 

8.  Chrome  ulceration  or  its  sequelae. 


9.  Eczematous  ulceration  of  the  skin  pro- 
duced by  dust  or  liquids,  or  ulceration  of 
the  mucous  membrane  of  the  nose  or 
mouth  produced  by  dust. 

10.  Epitheliomatous  cancer  or  ulceration  of 

the  skin  or  of  the  corneal  surface  of  the 
eye,  due  to  pitch,  tar  or  tarry  com- 
pounds. 

11.  Scrotal    epithelioma    (chimney-sweep's 

cancer). 

12.  The  disease  known  as  miners'  nystagmus, 

whether  occurring  in  miners  or  others, 
and  whether  the  symptom  of  oscillation 
of  the  eyeballs  be  present  or  not. 

13.  Glanders. 


14.  Compressed  air  illness  or  its  sequelae. 

15.  Subcutaneous    cellulitis    of    the    hand 

(beat  hand). 

16.  Subcutaneous  cellulitis  over  the  patella 

(miners'  beat  knee). 

17.  Acute  bursitis  over  the  elbow  (miners' 

beat  elbow). 

18.  Inflammation  of  the  synovial  lining  of 

the  wrist-joint  and  tendon  sheaths. 

19.  Cataract  in  glass  workers. 


Description  of  process 


20.  Telegraphist's  cramp. 

21.  Writer's  cramp. 


Any  process  involving  the  use  of  a  nitro  or 
amido  derivative  of  benzene  or  its  prepa- 
rations or  compounds. 

Any  process  involving  the  use  of  carbon  bi- 
sulphide or  its  preparations  or  compounds. 

Any  process  in  which  nitrous  fumes  are 
evolved. 

Any  process  in  which  nickel  carbonyl  gas  is 
evolved. 

Handling  of  arsenic  or  its  preparations  or 
compounds. 

Handling  of  lead  or  its  preparations  or  com- 
pounds. 

Any  process  in  the  manufacture  of  articles 
from  Gonioma  Kamassi  (African  boxwood). 

Any  process  involving  the  use  of  chromic 
acid  or  bichromate  of  ammonium,  potas- 
sium, or  sodium,  or  their  preparations. 


Handling    or    use    of    pitch,    tar,  or  tarry 
compounds. 


Chimney-sweeping. 
Mining.        ' 


Care  of  any  equine  animal  suffering  from 
glanders,  handling  the  carcass  of  such 
animal. 

Any  process  carried  on  in  compressed  air. 

Mining. 

Mining. 
Mining. 
Mining. 

Processes  in  the  manufacture  of  glass  in- 
volving exposure  to  the  glare  of  molten 
glass. 

Use  of  telegraphic  instruments. 


METHODS    AND    SCOPE    OF   LEGISLATION  817 

This  apparently  makes  a  list  of  27  diseases  subject  to  compensation. 
It  will  be  noted,  however,  that  two  of  these  (lead  poisoning  and  arsenic 
poisoning  among  the  diseases  added  by  the  secretary  of  state)  are  duplica- 
tions, inserted  merely  to  widen  the  scope  of  occupations  to  which  the  act 
applies,  the  "Description  of  Process"  in  both  cases  being  changed  to  include 
the  "handling"  as  well  as  the  "use"  of  the  dangerous  material. 

Under  the  British  law  expenses  of  medical  attendance  and  burial  up  to 
£10  are  paid  in  cases  of  death  if  there  are  no  dependents.  If  there  are,  they 
receive  a  maximum  sum  equal  to  3  years'  earnings,  with  minimum  and 
maximum  limits  of  £150  and  £300.  In  case  of  total  incapacity,  50  per  cent. 
of  wages  is  paid,  not  exceeding  £1  weekly,  while  for  partial  incapacity  the 
injured  workman  may  receive  the  entire  difference  between  his  earnings  be- 
fore and  after  illness. 

South  Australia. — The  precedent  set  by  Great  Britain  in  1906  has  been 
followed  by  two  of  her  colonies.  Five  years  after  the  passage  of  the  British 
law  South  Australia  repealed  its  earlier  compensation  code  and  adopted  a 
new  one,  scheduling  for  compensation  the  same  six  diseases  with  which 
occupational  disease  indemnity  had  begun  in  the  mother  country.  The 
rates  of  compensation  are,  however,  considerably  higher  than  in  Great 
Britain.  Burial  expenses  are  increased  to  £20,  and  the  minimum  compensa- 
tion to  dependents  is  £200  instead  of  £150.  For  partial  as  well  as  for  total 
disability  50  per  cent,  of  wages,  not  to  exceed  £1  a  week,  is  given.  On  the 
other  hand,  remuneration  for  disability,  instead  of  running  for  the  entire 
period,  is  limited  to  £300. 

Ontario. — In  1914  the  Canadian  province  of  Ontario  adopted  its  first 
workmen's  compensation  law,  modeled  after  that  of  England,  and  scheduling 
the  same  original  six  diseases.  Burial  expenses  are  limited  to  $75,  and 
compensation  to  dependents  to  $40  a  month.  Benefit  for  total  disability  is 
55  per  cent,  of  wages,  and  for  partial  disability  is  55  per  cent,  of  loss  of  earn- 
ing power,  both  payable  for  life. 

France. — In  France  the  principle  of  compensation  for  occupational  dis- 
eases is  recognized,  but  is  as  yet  limited  in  application  to  two  highly  infec- 
tious diseases.  A  section  of  the  financial  law  of  191 1  requires  employers 
of  miners  suffering  from  ankylostomiasis  to  bear  the  expense  of  all  medical 
treatment,  and  also  to  pay  benefits  during  the  treatment  equal  to  those 
established  under  the  accident  compensation  law — 66%  per  cent,  of  wages 
for  total  disability  and  50  per  cent,  of  loss  of  egft-ning  power  for  partial  dis- 
ability.    Anthrax  is  also  rated,  for  compensation  purposes,  as  an  accident. 

Germany. — In  Germany,  also,  anthrax  is  classed  as  an  accident  for  pur- 
poses of  compensation.  Moreover,  in  Germany,  as  well  as  in  many  other 
countries,  occupational  diseases  are  to  some  extent  taken  care  of  under 
national  systems  of  health  insurance.  The  rates  of  benefit  under  this  form 
of  insurance  are,  however,  much  lower  than  under  accident  insurance  or 
compensation,  and  consequently  sentiment  is  steadily  growing  in  favor  of 
52 


8i8  LEGISLATION   AND    GOVERNMENT    STUDY 

placing  diseases  directly  attributable  to  the  industry  in  the  latter  system, 
where  they  properly  belong.  The  strength  of  this  sentiment  in  Germany 
is  revealed  in  the  workmen's  insurance  code  of  191 1.  Here  it  is  provided 
that:  "By  decision  of  the  federal  council  the  accident  insurance  can  be  ex- 
tended to  specified  occupational  diseases  in  industries." 

Switzerland. — In  Switzerland  the  same  movement  is  also  in  progress. 
The  Swiss  federal  law  of  191 1  relating  to  sickness  and  accident  insurance 
provides  that  "the  federal  council  shall  prepare  a  list  of  substances,  the 
production  or  employment  of  which  occasions  dangerous  diseases.  Every 
disease  exclusively  or  essentially  due  to  the  action  of  one  of  these  substances 
in  an  enterprise  subject  to  insurance  is  deemed  an  accident  within  the  mean- 
ing of  the  present  law."  This  provision,  it  will  be  seen,  is  stronger  than 
that  in  the  German  code,  which  is  merely  permissive. 

Bulgaria. — Industrial  disability  compensation  in  Bulgaria  is  as  yet  limited 
to  employees  of  the  state,  but  for  them  the  law  of  1906  estabhshes  com- 
pensation for  accident  and  for  illness  if  it  "arises  out  of"  the  employment. 

Health  Insurance. — ^ While,  as  has  been  pointed  out,  the  benefits  to  the 
employee  under  a  system  of  health  insurance  are  lower  than  under  acci- 
dent compensation,  much  may  be  expected,  in  the  direction  of  occupational 
disease  prevention,  from  the  rapid  spread  of  compulsory  health  insurance 
throughout  the  world.  Ten  countries — Austria,  Germany,  Great  Britain, 
Holland,  Hungary,  Luxemburg,  Norway,  Roumania,  Russia  and  Serbia — 
already  have  such  compulsory  systems,  while  a  number  of  others,  Switzer- 
land, for  instance,  ofifer  subsidies  to  voluntary  health  funds.  An  active 
campaign  for  a  compulsory  health  insurance  system  is  now  under  way,  also, 
in  the  United  States. 

Conclusion.^ — At  a  time  when  the  health  of  the  people  receives  thoughtful 
attention,  and  sociologists,  lawyers  and  physicians  vie  with  one  another  in 
pressing  upon  national  legislatures  the  need  of  action,  the  effects  of  in- 
dustries upon  health  call  for  thougthful  study.  At  a  time  when  compensa- 
tion for  accidents  received  in  employments  is  the  most  actively  discussed 
phase  of  labor  legislation,  the  question  of  occupational  diseases  demands 
consideration. 

Gradually,  and  surely,  but  almost  without  realizing  it,  we  have  passed 
within  the  last  15  years  into  a  new  period  of  economic  history.  The  courts 
are  begining  to  get  a  new  perspective  on  life.  Century-old  precedents  based 
on  individuaUsm  are  trembling  in  the  balance.  Here  and  there  a  judge  shows 
clearly  that  he  has  been  studying  economics  as  well  as  law.  Recent  court 
decisions  clearly  indicate  that  protective  labor  legislation  will  be  sustained 
as  a  legitimate  exercise  of  the  police  power  when  it  is  made  apparent  that 
conditions  justify  such  interference  on  the  grounds  of  health. 

Future  labor  legislation,  and  court  decisions  which  mark  the  path  of  social 
progress,  will  be  based  upon  scientific  study  of  industrial  hygiene.  Only 
through  careful  study  can  we  secure  accurate  information  which  will  finally 


METHODS    AND    SCOPE    OF    LEGISLATION  819 

enable  us  to  establish  scientific  standards.  The  establishment  of  such 
standards  is  prerequisite  to  intelligent  legislation,  to  enlightened  court 
opinions,  and  to  efl&cient  enforcement  of  the  law. 

While  such  researches  are  under  way,  we  should  emphasize  at  every 
opportunity  the  following  considerations:  (i)  all  preventable  occupational 
diseases  must  be  prevented;  (2)  those  occupational  diseases  which  we  do 
not  yet  know  how  to  prevent  must  be  reduced  to  a  minimum;  and  (3)  the 
victims  of  occupational  disease  must  be  compensated  for  their  injuries  by 
some  just  system  of  insurance. 


CHAPTER  II 
THE   NOTIFICATION   OF   OCCUPATIONAL   DISEASES 

BY  JOHN  W.  TRASK,  M.  D.,  Washington,  D.  C. 

For  most  adults  labor  is  a  necessity.  Each  must  do  the  equivalent  in 
work  of  the  labor  necessary  to  clothe,  feed,  and  house  himself.  If  he  does  not, 
some  one  must  do  it  for  him.  Work  is  not  only  necessary,  but  if  done  under 
proper  conditions  is  beneficial  to  the  individual;  it  exercises,  develops  and 
trains  his  mind  and  body  and  makes  life  more  pleasant.  Work  should  be 
beneficial  to  and  not  destructive  of  the  worker;  it  should  be  physiological 
and  not  pathological. 

There  are  few  industries  which  do  not  or  may  not  cause  ailments  or 
disabilities  among  those  engaged  in  them.  In  some  the  worker  is  merely 
made  more  susceptible  to  certain  diseases,  in  others  actual  disease  is  produced 
unless  proper  precautions  are  taken  to  safeguard  the  employee's  health.  In 
industrial  communities  a  considerable  proportion  of  all  diseases  and  ill- 
nesses among  wage  earners  is  due  directly  or  indirectly  to  occupation  or  to 
conditions  associated  with  labor.  In  such  communities  a  large  part  of 
public  hygiene  relates  to  the  industries. 

The  ever  increasing  complexity  of  our  civilization  and  especially  the  in- 
creasing complexity  of  our  industrial  life,  with  its  rapid  development,  its 
introduction  of  new  machinery  and  processes,  has  introduced  new  occupations, 
new  industrial  poisons,  and  new  occupational  hazards.  The  conditions  of 
labor  and  the  environment  of  the  worker  have  changed  much  in  the  last 
30  years.  Some  of  the  changes  have  been  to  the  worker's  advantage;  others 
have  been  to  his  detriment,  physical  or  mental.  The  worker's  labor  should 
add  to  his  welfare  and  be  a  factor  in  increasing  his  well-being.  It  should  not 
be  a  cause  of  injury.  Occupation  ceases  to  be  a  source  of  profit  to  the 
worker  if  it  takes  from  him  not  only  his  time  and  labor  but  his  health  as  well 
and  causes  physical  or  mental  injury  or  disease.  The  making  of  white 
phosphorus  matches  has  been  legislated  out  of  existence  in  the  United  States 
because  it  crippled  and  mutilated  men.  Other  industrial  processes  that 
multilate  and  kill  will  probably  meet  a  similar  fate. 

The  attention  being  given  to  the  matter  is  indicated  to  some  extent 
by  the  fact  that  within  the  last  5  years  the  legislatures  of '15  states  have 
enacted  laws  requiring  physicians  to  report  to  the  authorities  cases  of  certain 
occupational  diseases  occurring  in  persons  treated  bv  them. 

Why  Cases  of  Occupational  Disease  Should  be  Reported. — A  disease 
may  be  prevented  l)y  entirely  removing  the  cause  from  the  community  and 

820 


THE    NOTIFICATION    OF    OCCUPATIONAL   DISEASES  82 1 

rendering  it  impossible  for  the  cause  to  again  gain  entrance.  Theoretically 
leprosy  could  be  eliminated  from  a  locality  by  removing  all  lepers  and 
preventing  infected  individuals  from  again  coming  in.  Phosphorus  poison- 
ing has  been  practically  eliminated  from  the  United  States  by  the  act  of 
Congress  placing  a  prohibitive  tax  upon  the  manufacture  of  white  phos- 
phorus matches.  However,  there  are  few  diseases  which  can  be  prevented 
in  this  way.  From  the  standpoint  of  the  community  most  of  the  so-called 
preventable  diseases  must  be  controlled.  Only  a  few  can  be  absolutely 
eliminated. 

To  control  a  given  disease  a  primary  requisite  is  to  know  where  and 
under  what  conditions  cases  of  the  disease  are  occurring.  This  is  equally 
true,  whether  the  disease  is  plague,  cholera,  typhoid  fever,  tuberculosis, 
lead  or  arsenic  poisoning,  or  compressed-air  illness,  for  each  case  shows  the 
existence  of  conditions  capable  of  producing  the  disease,  conditions  which 
should  be  remedied,  so  that  others  will  not  be  subsequently  affected  from 
the  same  source.  The  notification  of  cases  is  as  important  in  the  control  of 
occupational  diseases  as  it  is  in  the  control  of  communicable  diseases. 

The  notification  of  cases  of  occupational  diseases  will,  however,  have 
little  other  than  statistical  value  unless  the  source  of  each  case  is  investigated 
by  some  competent  person.  This  is  especially  true  of  the  industrial  poison- 
ings. The  investigation  of  the  conditions  under  which  each  case  arises 
should  lead  to  such  changes  as  will  prevent  the  infliction  of  similar  injury 
to  others.  The  accomplishment  of  this  should  be  the  purpose  of  case  reports, 
and  the  desire  of  the  community,  the  employer,  the  patient  and  the  attend- 
ing physician. 

By  Whom  Reports  Are  Made. — Reports  of  the  occurrence  of  occupational 
diseases  are  necessarily  made  by  physicians,  for  because  of  their  training 
they  are  as  a  class  the  only  persons  capable  of  recognizing  the  nature  of 
maladies  and  of  ascribing  them  to  their  true  causes.  However,  the  average 
physician  is  prone  to  fail  to  recognize  the  etiologic  relation  of  occupation  in 
his  cases.  This  is  due  in  large  measure  to  the  fact  that  many  occupational 
diseases  are  of  comparatively  recent  origin,  being  the  result  of  industries  or 
manufacturing  processes  developed  mainly  in  the  last  20  or  30  years.  As  a 
result,  but  little  regarding  them  is  found  in  the  literature  accessible  to  and 
used  by  practising  physicians.  Nor  has  the  teaching  of  the  intimate  rela- 
tion of  occupation  to  the  diseases  found  in  industrial  communities  made 
its  way  into  the  curriculums  of  many  of  our  medical  schools.  Nevertheless, 
the  physician  is  the  one  whose  training  best  fits  him  to  recognize  cases  of 
industrial  disease  and,  besides,  he  is  the  one  who  sees  most  of  the  sick,  at 
least  a  greater  proportion  than  any  one  else.  It  is  necessary,  therefore,  to 
rely  upon  the  medical  practitioner  for  information  as  to  when  and  where  cases 
are  occurring,  and  for  this  reason  the  progress  made  in  the  control  and  pre- 
vention of  occupational  diseases  and  in  the  advancement  of  industrial  hy- 
giene will  depend  largely  upon  his  cooperation.     The  medical  profession 


822  LEGISLATION   AND    GOVERNMENT    STUDY 

can  make  the  control  of  occupational  diseases  a  thing  of  early  accomplish- 
ment or  can  retard  it  for  a  long  time. 

The  laws  of  the  states  of  Illinois,  Missouri,  New  Jersey,  Ohio,  and  Pennsyl- 
vania require  employers  to  cause  all  employees  engaged  in  certain  harmful 
kinds  of  work  or  processes  to  be  examined  at  least  once  a  month  to  ascertain 
whether  the  nature  of  the  work  has  caused  injury  or  illness.  The  physicians 
making  these  examinations  will  undoubtedly  become  more  and  more  expert 
and  will  recognize  occupational  morbidity  with  greater  facility  and  certainty 
than  do  the  physicians  who  see  fewer  cases.  The  examining  of  employees  in 
this  way  will  bring  to  attention  practically  all  the  illnesses  with  which  they 
are  afflicted  and  among  these  will  be  cases  that  would  have  otherwise  never 
been  brought  to  the  attention  of  a  physician. 

To  Whom  Reports  are  Made. — In  some  states  the  physician  reports  cases 
of  occupational  disease  to  the  state  department  of  labor,  but  in  most  of  the 
15  states  requiring  notification  the  reports  are  sent  to  the  state  board  of 
health.  In  one  state  they  are  sent  both  to  the  state  board  of  health  and 
to  the  department  of  labor.  In  several  of  the  states  in  which  the  reports  are 
sent  to  the  health  department,  that  department  is  required  to  send  copies 
immediately  to  the  labor  office. 

The  chief  purposes  of  morbidity  reports,  that  is,  reports  of  cases  of 
sickness,  being  that  each  case  may  be  known  and  investigated,  faulty  con- 
ditions remedied  and  the  occurrence  of  the  disease  in  others  prevented, 
reports  must  reach  without  delay  the  officials  who  will  investigate  the 
reported  cases  and  institute  measures  to  protect  others.  In  the  notification 
of  the  ordinary  communicable  diseases  the  reports  are  sent  to  the  local  health 
officer,  for  he  is  the  one  who  must  get  the  information  promptly  and  act 
upon  it.  Reports  of  occupational  diseases  are  sent  to  the  state  department  of 
labor  by  the  physician,  either  directly  or  indirectly  through  the  health 
department,  when  the  labor  department  is  the  one  having  the  authority  and 
means  to  investigate  and  correct  conditions  deleterious  to  the  health  of  em- 
ployees. The  physician  is  accustomed  to  report  cases  of  sickness  to  the  health 
department,  so  that  adding  occupational  diseases  to  those  previously  noti- 
fiable is  merely  extending  the  scope  of  a  practice  with  which  he  is  already 
familiar.  When  the  department  of  health  receives  these  reports  it  must, 
however,  immediately  forward  the  information  thus  acquired  to  the  labor 
department  or  be  in  a  position  to  itself  investigate  and  correct  faulty  indus- 
trial conditions.  Most  of  the  value  of  the  notification  of  cases  of  occupa- 
tional diseases  is  lost  when  the  reports  are  intended  merely  for  purposes  of 
record.  Under  such  conditions  they  serve  mainly  as  statistical  data  to 
indicate  what  has  happened  in  the  past,  data  incomplete  and  containing 
many  undiscovered  errors  because  not  investigated,  data  therefore  likely  to 
be  untrue  and  undependable. 

The  State's  Right  to  Require  Reports. — The  right  of  the  state  to  require 
physicians  to  report  cases  of  disease  has  been  repeatedly  declared  by  the 


THE    NOTIFICATION    OF    OCCUPATIONAL    DISEASES  823 

courts.  The  state  that  issues  to  an  individual  a  license  to  practise  medicine 
certainly  can  stipulate  under  what  conditions  the  practice  shall  be  carried 
on.  From  time  to  time  states  have  passed  laws  allowing  physicians  a  fee  for 
each  case  of  notifiable  disease  reported.  The  payment  of  a  fee  gives  the  re- 
port the  semblance  of  a  business  transaction,  at  least  the  physician  is  likely 
to  receive  that  impression  and  to  feel  that  if  he  does  not  want  the  fee,  he  need 
not  make  the  report.  A  small  fee  is  but  little  inducement  to  a  busy  practi- 
tioner, and  it  has  been  suggested  that  a  large  fee  might  be  the  cause  of 
numerous  erroneous  notifications.  The  importance  of  these  reports  to  the 
community  is  too  great  to  allow  of  their  being  placed  on  a  commercial  basis. 
As  well  give  chauffeurs  a  fee  for  each  time  they  are  inconvenienced  or  delayed 
by  keeping  within  the  speed  limits. 

The  paying  of  a  fee  for  morbidity  reports  has  not  been  successful,  for  in 
reviewing  the  results  being  obtained  in  the  notification  of  the  communicable 
diseases  it  is  found  that  on  the  whole  the  states  which  pay  a  fee  for  each 
report  are  getting  poorer  results  and  less  complete  reports  than  the  states 
which  pay  no  fee. 

The  Information  Given  in  Reports. — The  department  whose  duty  it  is 
to  investigate  reported  cases  of  occupational  diseases  and  cause  such  changes 
to  be  made  as  will  prevent  the  occurrence  of  additional  cases  must  have 
detailed  information  of  each  case.  For  the  purpose  of  understanding  the 
circumstances  under  which  the  illness  was  contracted  it  will  want  to  know' 
the  nature  of  the  existing  illness  and  its  time  of  onset,  the  age  and  sex  of  the 
patient,  the  nature  of  the  industry  in  which  he  worked,  the  particular  kind 
of  work  at  which  he  was  employed,  the  place  where  employed,  the  length  of 
time  he  worked  in  his  last  position  and  the  place  or  places  where  he  had 
previously  worked,  the  length  of  time  he  has  worked  at  his  present  occupation 
and  the  kinds  of  work  engaged  in  before.  There  is  other  information 
that  will  be  desired  for  purposes  of  record  and  statistical  analysis.  Still 
other  data  having  direct  and  important  bearing  will  be  brought  out  during 
the  investigation  6f  the  case  and  the  conditions  under  which  it  arose,  all 
of  which  the  investigator  will  record.  The  question  which  naturally  arises 
is  how  much  of  this  information  should  be  contained  in  the  primary  report 
made  by  the  physician  and  how  much  should  be  gathered  by  the  health  de- 
partment or  labor  department,  whichever  is  in  charge  of  industrial  sanitation; 
how  much  of  the  data  can  the  attending  physician  furnish  and  how  much 
should  be  expected  of  him.  It  would  seem  that  the  physician  should  not 
be  asked  to  give  information  which  can  be  obtained  more  satisfactorily  or 
with  greater  accuracy  in  some  other  way,  but  that  he  should  give  that  in- 
formation which,  because  of  his  special  knowledge  of  disease  and  as  the 
physician  in  attendance  on  the  patient,  he  alone  can  give.  He  might  also 
properly  give  such  other  data  as  can  be  readily  obtained  by  him  and  are 
necessary  to  enable  the  proper  authority  to  investigate  the  industrial  con- 


824  LEGISLATION   AND    GOVERNMENT    STUDY 

ditions  responsible  for  the  illness,  including  the  nature  of  the  disease,  the  name 
and  address  of  the  patient  and  the  place  where  employed. 

The  Importance  to  the  Physician  of  a  Knowledge  of  Occupational  Haz- 
ards.—In  the  proper  treatment  of  the  sick  a  clear  understanding  of  the 
nature  of  the  illness  and  usually  of  its  cause  and  of  the  circumstances  and 
conditions  in  the  life  of  the  patient  which  have  contributed  to  or  been 
responsible  for  the  disease  is  necessary.  To  acquire  this  knowledge,  informa- 
tion of  the  patient's  occupation  and  its  relation  to  the  illness  must  be  ob- 
tained. The  practising  physician  needs,  therefore,  to  be  familiar  with  the 
industries  of  his  community  and  the  morbid  efifects  which  they  are  liable  to 
produce  in  those  engaged  in  them.  Otherwise,  he  will  frequently  fail  to 
make  a  proper  diagnosis,  will  fail  in  treatment,  and  will  be  unable  to  give  his 
patient  the  necessary  advice  to  prevent  recurrence  of  the  illness. 

The  Relation  of  Occupational  to  Other  Diseases.^ — Occupational  diseases 
are  diseases  produced  as  a  result  of  the  nature  of  the  patient's  occupation  or 
employment.  They  cannot  be  put  into  a  class  by  themselves.  Few  dis- 
eases are  produced  only  by  occupation.  Many  morbid  conditions  may  be 
produced  as  a  result  of  the  nature  of  the  patient's  employment  or  may  be 
due  to  other  causes.  The  diagnosis,  therefore,  does  not  usually  show 
whether  the  morbid  process  should  be  classed  as  an  occupational  disease. 
However,  a  knowledge  of  the  patient's  occupation  and  its  possibilities  for 
"harm  to  those  engaged  at  it  will  suggest  the  likelihood  of  the  illness  being 
caused  thereby. 

Compressed-air  illness  and  certain  tics  and  palsies  are  almost  invariably 
due  to  occupation.  So  was  phosphorus  poisoning  in  the  United  States  before 
Congress  placed  a  prohibitive  tax  on  the  manufacture  of  white  phosphorus 
matches  and  in  that  way  put  an  end  to  the  industry.  Anthrax  is  usually 
contracted  as  a  result  of  the  nature  of  the  patient's  employment. 

Lead  poisoning  is  also  usually  acquired  as  a  result  of  the  patient's  work. 
There  are  considerably  more  than  loo  different  trades  in  which  the  workmen 
may  get  this  metal  into  their  bodies  and  be'poisoned  as  a  result.  It  is  to  be 
borne  in  mind  that  workers  in  lead  may  show  no  symptoms  usually  con- 
sidered indicative  of  plumbism  and  yet  be  suffering  from  its  effects.  The 
existence  of  such  a  condition  in  a  patient  should  be  recognized  by  the 
physician,  for  its  effect  on  ailments  supposedly  due  directly  to  other  causes 
may  be  considerable.  Chronic  nephritis  and  arteriosclerosis  may  be  due 
to  lead  poisoning  or  to  other  causes. 

Tuberculosis  may  very  probably  be  produced  as  a  result  of  lessened 
resistance  to  the  disease  due  to  injury  done  to  lungs  by  the  continued  inhala- 
tion of  various  irritating  dusts.  Many  occupations  have  associated  with 
them  ailments  which  occur  among  those  engaged  at  them  more  frequently 
than  among  others.  Some  occupations  by  their  insidious  efifects  seem  to 
shorten  merely  the  life  of  the  worker;  others  produce  chronic  disease  which 


THE    NOTIFICATION   OF    OCCUPATIONAL   DISEASES  825 

in  time  causes  an  incapacity  for  work  and  compels  the  laborer  to  abandon  his 
trade. 

State   Laws   Requiring   the  Notification   of   Occupational  Diseases. — 

Laws  requiring  that  physicians  report  to  designated  authorities  cases  of 
occupational  disease  among  their  patients  are  of  comparatively  recent 
origin.  They  represent  a  transition  from  the  period  when  the  control  of  un- 
healthful  industries  consisted  solely  in  the  enactment  of  laws  requiring  the 
installation  of  safeguards  in  certain  industries,  and  the  regulation  of  some  of 
the  conditions  under  which  work  was  performed,  to  the  period  in  which  effect- 
ive work  is  to  be  accomplished  in  the  control  of  occupational  diseases — work 
that  will  be  effective  because  it  will  be  done  with  a  definite  knowledge  of  the 
industries  in  which  the  health  of  the  workers  is  being  undermined,  and  not 
only  of  the  industries  but  of  the  particular  factories  and  establishments. 
The  transition  is  from  the  indefinite  generalized  effort  usual  in  the  absence 
of  satisfactory  knowledge  to  the  more  direct  and  effective  measures  based 
upon  definite  information  and  a  clear  understanding.  Each  reported  case 
gives  notice  of  a  factory  or  workshop  where  the  conditions  are  such  that  the 
workmen  are  being  deprived  of  health. 

The  legislation  in  the  United  States  has  been  patterned  to  some  extent 
after  that  of  Great  Britain.  The  bills  passed  by  most  of  the  state  legislatures 
have  been  copies  or  modifications  of  a  standard  bill  drafted  by  the  American 
Association  for  Labor  Legislation. 

The  first  legislation  in  the  United  States  requiring  the  notification  of 
occupational  diseases  was  enacted  in  191 1,  when  six  states  passed  laws. 
These  states  were  Cahfornia,  Connecticut,  Ilhnois,  Michigan,  New  York, 
and  Wisconsin.  The  California  law  was  approved  April  21,  191 1,  and  has 
the  distinction  of  being  the  oldest  of  the  laws.  Two  states,  Maryland  and 
New  Jersey,  passed  laws  in  19 12,  and  seven  states,  Maine,  Massachusetts, 
Minnesota,  Missouri,  New  Hampshire,  Ohio  and  Pennsylvania,  followed  in 
1913,  and  Rhode  Island  in  1915. 

The  laws  of  Illinois,  Missouri,  New  Jersey,  Ohio  and  Pennsylvania 
require  that  employers  in  industries  in  which  the  workers  come  into  such 
contact  with  certain  harmful  processes  or  materials  that  injury  may  be  caused 
to  their  health  shall  have  the  employees  examined  by  a  physician  at  least 
once  a  month  to  ascertain  whether  any  occupational  disease  (in  New  Jersey 
lead  poisoning  only)  exists.  Of  this  type  of  law  that  of  Missouri  is  the 
most  comprehensive  and  contains  the  following  provisions: 

Provisions  of  Missouri  Law.- — Employees  engaged  in  manufacture  in 
which  antimony,  arsenic,  brass,  copper,  lead,  mercury,  phosphorus,  zinc, 
their  alloys  or  salts,  or  any  poisonous  chemicals,  minerals,  acids,  fumes, 
vapors,  gases  or  other  substances  are  generated,  used  or  handled  by  employees 
in  harmful  quantities,  or  under  harmful  conditions,  are  required  at  least 
once  a  month  to  cause  all  employees  coming  into  direct  contact  with  the 
poisonous  agencies  to  be  examined  by  a  physician  to  ascertain  whether  there 


826  LEGISLATION   AND    GOVERNMENT   STUDY 

exists  in  the  employees  any  disease  due  or  incident  to  the  character  of  the 
work  in  which  the  employees  are  engaged.  The  physicians  making  these 
examinations  are  to  make  within  24  hours  a  report  to  the  state  board  of 
health  in  triplicate  upon  blanks  furnished  by  said  board.  If  disease  incident 
to  occupation's  found,  the  report  is  to  state  the  name,  address  and  business 
of  the  employer,  the  nature  of  the  disease,  and  its  probable  extent  and  dura- 
tion, the  name  of  the  employee  and  his  last  place  and  length  of  employment. 

Upon  receipt  of  these  reports  the  secretary  of  the  state  board  of  health 
is  to  send  one  copy  to  the  state  factory  inspector  and  one  copy  to  the  superin- 
tendent of  the  factory  in  which  the  employee  is  supposed  to  have  contracted 
his  ailment. 

The  enforcement  of  the  law  is  made  the  duty  of  the  state  factory  inspector. 

Failure  on  the  part  of  a  physician  to  make  the  required  reports  is  made  a 
misdemeanor  punishable  by  a  fine  of  not  less  than  $50.  (Act  approved 
March  27,  1913;  effective  June  23,  1913.) 

Provisions  of  Other  State  Laws. — The  Massachusetts  law  merely  pro- 
vides that  the  state  board  of  labor  and  the  industrial  accident  board,  sitting 
jointly,  shall  make  regulations  for.  the  prevention  of  occupational  diseases. 
This  joint  board  is  given  authority  to  require  physicians  to  report  all  cases 
in  which  the  patient  is  suffering  from  any  ailment  or  disease  contracted  as  a 
result  of  the  nature,  circumstances  or  conditions  of  employment. 

The  other  state  laws  provide  that  medical  practitioners  shall  report  to 
a  designated  state  authority  all  cases  in  their  practices  of  certain  diseases, 
usually  occupational  in  origin.  These  diseases  include  poisoning  by  lead, 
phosphorus,  arsenic,  mercury,  wood  alcohol,  or  brass  or  their  compounds, 
compressed-air  illness  and  anthrax.  In  some  of  the  states  the  above-named 
diseases  are  to  be  reported  only  when  they  have  been  contracted  as  a  result 
of  the  nature  of  the  patient's  employment.  This  includes  practically  all 
cases  excepting  those  of  intentional  or  accidental  poisoning  by  mercury, 
arsenic  and  wood  alcohol.  In  some  of  the  states  all  diseases  due  to  occupa- 
tion are  to  be  reported.  The  New  Hampshire  law  illustrates  this  type  and 
makes  the  following  provisions: 

Provisions  of  New  Hampshire  Law. — Physicians  are  to  report  all  cases 
among  their  patients  believed  to  be  suffering  from  poisoning  from  lead, 
phosphorus,  arsenic,  brass,  wood  alcohol,  or  mercury  or  their  compounds,  or 
from  anthrax  or  compressed-air  illness,  or  from  any  other  ailment  contracted 
as  a  result  of  the  nature  of  the  patient's  employment.  These  reports  are 
to  be  made  to  the  state  board  of  health  within  48  hours  and  are  to  give  the 
name,  address  and  occupation  of  the  patient,  the  name,  address  and  business 
of  the  employer,  the  nature  of  the  disease  and  such  other  information  as  may 
be  required  by  the  state  board  of  health. 

The  state  board  of  health  is  to  prepare  and  issue  blank  forms  on  which 
the  reports  are  to  be  made  by  physicians,  and  is  to  transmit  copies  of  reports 
received  to  the  Commissioner  of  Labor. 


THE    NOTIFICATION   OF    OCCUPATIONAL   DISEASES  827 

Violations  of  the  law  on  the  part  of  physicians  are  made  punishable  by 
a  fine  of  $5  for  each  offense.     (Act  approved  May  7,  1913;  effective  July  i, 

1913-) 

Analytical  Summary  of  State  Laws.— The  occupational  diseases  required 
by  the  state  laws  to  be  reported  are  anthrax,  compressed-air  illness  and  cer- 
tain industrial  poisonings;  poisoning  from  lead  or  its  compounds  is  mentioned 
in  14  of  the  laws;  poisoning  from  phosphorus,  arsenic  or  mercury,  or  their 
compounds,  and  compressed-air  illness  are  specified  in  12  of  the  acts;  poison- 
ing from  brass  or  wood  alcohol  is  included  in  5,  and  in  11  anthrax  is  named. 
In  7  of  the  laws  it  is  stated  that  all  occupational  diseases  shall  be  reported. 

The  information  to  be  given  in  the  physicians'  reports  differs  to  some 
extent.  In  14  of  the  states  the  patient's  name  and  address  are  to  be  given, 
in  8  his  occupation  and  place  of  employment,  in  2  the  duration  of  employ- 
ment and  of  the  disease,  in  13  the  nature  of  the  disease,  in  5  the  name  of  the 
employer,  and  in  4  his  address  and  business. 

In  II  of  the  states  the  physicians  are  to  send  their  reports  to  the  state 
department  of  health  or  board  of  health,  in  3  to  the  state  commission  of  labor 
or  labor  bureau,  and  in  i  state  to  both  the  labor  and  health  departments. 

In  8  of  the  states  in  which  the  reports  are  made  to  the  state  board  of 
health,  the  health  department  forwards  the  reports  or  transcripts  thereof 
to  the  proper  labor  oflice.  In  i  state,  ^Maryland,  the  department  of  health 
transmits  the  data  to  the  state  bureau  of  statistics  and  information. 

In  4  states  the  physicians  are  to  make  their  reports  at  once,  in  i  within 
24  hours,  in  5  within  48  hours,  in  i  within  10  days,  and  in  i  within  30  days. 

Penalties  for  failure  on  the  part  of  the  physician  to  report  have  been  pro- 
vided in  II  states.  They  include  both  fines  and  imprisonment.  The  fines 
vary  from  not  over  S5  in  Maryland  to  one  of  not  less  than  $50  in  Missouri. 
In  Minnesota  the  penalty  is  a  fine  of  not  over  Sio  or  imprisonment  for  not 
over  ID  days. 

In  4  states  it  is  made  the  duty  of  the  state  health  department  to  enforce 
the  law,  in  6  of  the  state  labor  department. 

In  2  states,  California  and  Connecticut,  a  fee  of  50  cts.  is  paid  to  physicians 
for  each  report  made. 

Enforcement  of  Notification  Laws. — The  comparatively  small  number  of 
cases  of  occupational  diseases  as  yet  reported  in  those  states  having  laws  re- 
quiring notification  is  due  in  part  to  the  failure  on  the  part  of  physicians  to 
recognize  the  true  nature  of  such  cases.  Another  factor  is  undoubtedly  that 
the  requirement  of  notification  is  comparatively  new,  being  in  no  instance 
much  over  4  years  old,  and  that  physicians  have  not  as  yet  become  accus- 
tomed to  report,  although  in  most  of  the  states  the  physicians  have  been  cir- 
cularized once  or  more  for  the  purpose  of  making  known  to  them  their  duties 
as  specified  in  the  notification  laws.  There  can  be  little,  if  any,  question  that 
considerate  but  nevertheless  watchful  enforcement  would  materially  increase 
the  number  of  reports.    Flagrant  violations  of  the  law  certainly  should  be  prose- 


828  LEGISLATION    AND    GOVERNMENT    STUDY 

cuted,  and  particularly  because  of  the  value  this  course  would  have  in  im- 
pressing all  concerned  with  the- need  of  complying  with  the  statutes.  Those 
whose  duty  it  is  to  enforce  these  recently  enacted  laws  for  the  notification  of 
occupational  diseases  have  a  heavy  responsibility,  for  much  always  depends 
upon  the  manner  of  enforcement  of  a  new  law  during  the  period  immediately 
following  its  enactment.  It  is  much  easier  to  enforce  a  law  from  the  beginning 
than  to  bring  back  to  life  one  that  has  been  a  dead  letter  for  a  time.  The 
future  of  the  notification  of  cases  of  industrial  diseases  will  be  influenced  to 
a  marked  degree  by  the  intelligence  and  earnestness  of  those  who  now  have 
the  responsibiUty  of  enforcing  these  laws.  The  enforcement  of  laws  is  more 
important  than  theij  enactment. 

Those  who  will  be  benefited  most  by  the  reporting  of  occupational  dis- 
eases and  by  the  improvement  in  the  sanitary  conditions  in  trades  and  in- 
dustries which  will  follow  are  naturally  the  laborers,  the  workmen  and  the 
workwomen.  These  should  take  a  keen  interest  in  having  every  case  of 
occupational  disease  reported  as  required  by  law.  The  matter  is  one  also 
of  interest  to  labor  unions,  to  fraternal  organizations  having  sick  or  death 
benefit  features,  and  to  the  insurance  companies  devoted  largely,  or  in  part, 
to  industrial  insurance,  all  of  which  can  be  of  material  assistance  to  secure 
the  enforcement  of  the  notification  laws. 

Blank  Forms  in  Use. — The  blank  forms  used  by  the  several  states  differ 
to  some  extent,  depending  upon  the  requirements  of  the  law  regarding  the 
notification  of  cases  of  occupational  diseases.  Several  of  the  states,  among 
which  may  be  mentioned  New  Jersey,  New  York,  New  Hampshire,  and 
Maryland,  use  the  same  form  of  blank,  a  copy  of  which  is  here  reproduced. 

Mortality  Records  of  Occupational  Diseases. — The  standard  blank  form 
approved  by  the  United  States  Bureau  of  the  Census  for  use  in  the  making  of 
death  certificates  contains  a  space  for  a  statement  of  the  occupation  of  the 
deceased.  With  this  information  of  the  nature  of  the  occupation  it  is  pos- 
sible to  classify  the  deaths  according  to  the  kind  of  work  in  which  the  de- 
cedents were  engaged.  To  be  able  to  do  this  is  highly  desirable,  for  although 
it  does  not  show  the  origin  of  the  diseases  causing  death,  that  is,  whether 
they  were  due  to  occupation,  it  nevertheless  makes  it  possible  to  know 
whether  those  engaged  in  any  particular  work  have  on  the  average  a  shorter 
duration  of  life,  or  die  in  greater  numbers  of  any  one  disease,  or  are  killed  in 
greater  numbers  by  accidents  than  is  true  of  people  in  general. 

The  statements  of  occupations  made  in  death  certificates  are  in  no  wise 
a  substitute  for  the  reporting  by  physicians  of  cases  of  occupational  disease, 
nor  does  the  notification  of  disease  serve  as  a  substitute  for  the  statement  of 
occupation  made  in  the  death  certificates.  They  furnish  entirely  different 
information  and  serve  quite  different  purposes.  The  notification  of  cases  of 
disease  due  to  occupation  shows  when  and  where  occupational  diseases  are 
occurring  at  a  time  when  it  is  usually  possible  for  an  investigation  to  be 
made  to  ascertain  whether  the  cas?  is  truly  due  to  occupation,  and  to  study 


THE    NOTIFICATION    OF    OCCUPATIONAL   DISEASES 


829 


PERSONAL  AND  STATISTICAL  PARTICULARS! 


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CERTIFICATE  OF  INDUSTRIAL  DISEASE 

NAME  OF  PATIENT 

ADDRESS  :  Street  and  No City  or  Village 


Sex  Age  Color         Country  of  birth 


MEDICAL  CERTIFICATE  OF  DISEASE 


Single,  married,  widowed  or 
divorced  (write  the  word) 


Occupation 
(a)  Present  trade,  profession  or  work. 


Diagnosis  of  present  illness 

Chief  symptoms  and  conditions. 


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Particular  kind  of  work  in  such  trade,  etc. 


Date  first  symptoms  appeared. 


Date  of  entering  present  occupation 

Employer's  name 

Address 

Business  (kind  of  goods  made  or  work  done) .  . 


(b)  Previous  occupations: 

XT  f  ^-  Entered  Left 

Name  of  occupation  ^^^^^  ^^^^^^ 


Previous  illnesses,  if  any,  due  to  occupation. 
Disease  or  illness  Year 


CompUcating  diseases  (such  as  alcoholism, 
syphilis,  tuberculosis,  etc.) 


Additional  facts. 


Date  of  diagnosis . 
(Signed) 


. ,  igi .  .  .   (Address) . 


.,    191.  .  . 

.  .  M.  D 


830  LEGISLATION   AND    GOVERNMENT    STUDY 

and  remedy  the  conditions  which  made  it  possible  for  the  disease  to  have  been 
so  contracted.  The  statements  of  occupation  in  death  certificates  show  the 
duration  of  Hfe  of  those  engaged  at  various  kinds  of  work  and  the  terminal 
diseases  and  accidental  injuries  of  which  they  die. 

The  value  and  accuracy  of  these  data  in  death  certificates  depend  almost 
entirely  upon  the  care  and  attention  given  by  the  physician  in  stating  the 
cause  of  death  and  by  members  of  the  decedent's  family  in  stating  the  exact 
nature  of  the  occupation  of  the  decedent.  It  is  impossible  to  compile 
statistically  the  occupations  and  causes  of  death  if  erroneously  given  and 
arrive  at  results  which  are  dependable  and  show  conditions  as  they  actually 
are.  A  death  certificate  properly  filled  out  should  show  not  only  the  in- 
dustry in  which  the  decedent  was  engaged,  but  also  the  particular  kind  of  work 
at  which  he  was  employed.  For  example,  50  years  ago  a  statement  that  a  man 
was  a  printer  described  his  occupation  in  a  fairly  satisfactory  manner,  for 
in  most  shops  the  workmen  practically  all  did  the  same  kinds  of  work.  But 
this  is  not  sufiicient  at  the  present  time  with  the  development  of  large 
shops  and  the  differentiation  of  labor.  A  printer  may  be  a  pressman  or  he 
may  be  a  compositor.  A  compositor,  on  the  other  hand,  may  be  a  hand 
typesetter  or  a  typesetting  machine  operator.  But  the  typesetting  machines 
most  commonly  used  are  of  two  kinds:  the  linotype,  in  which  the  molten  type 
metal  is  cast  in  the  same  machine  at  which  the  operator  works,  and  the 
monotype,  in  which  the  keyboard  is  entirely  detached  from  the  molten  metal 
which  may  be  cast  in  a  different  room  or  even  in  a  different  building.  The 
monotype  keyboard  operator  may  in  no  wise  be  exposed  to  the  dust  or  fumes 
of  lead,  while  the  hand  compositor  and  the  linotype  operator  are  both  subject 
to  such  exposure.  For  these  reasons  the  exact  nature  of  the  work  performed 
is  essential  to  a  proper  understanding  of  the  occupation.  The  same  need 
for  describing  the  particular  labor  performed  is  equally  necessary  in  other 
trades  and  occupations  if  the  derived  statistics  are  to  be  of  value. 


CHAPTER  III 

THE  PROTECTION  AND  PROMOTION  OF  THE  HEALTH  OF 
WOMEN  WAGE  EARNERS 

BY  IRENE  OSGOOD  ANDREWS,  New  York  City,  N.  Y. 

Because  of  the  physical  differences  between  men  and  women,  working  / 
women  are  exposed  to  health  dangers  which  do  not  so  seriously  threaten 
men.  With  a  physique  slighter  and  less  strong,  woman  has  not  the  same 
power  to  resist  conditions  which  insidiously  break  down  health  and  which 
predispose  to  more  serious  disturbances.  She  has,  therefore,  been  given  by 
most  civilized  countries  special  legislative  protection. 

In  sharp  contrast  with  the  leisurely,  easy-going  methods  found  in  the 
early  stages  of  factory  production,  practically  all  countries  have  seen  a  new 
and  threatening  strain  created  in  industry  by  the  introduction  of  machinery 
followed  by  constant  speeding  up,  by  an  ever  increasing  number  of  machines 
to  be  handled  or  attended  by  one  person,  and  by  the  requirement  of  a  con- 
stantly enlarged  output.  The  complexity  of  modern  industry  and  machinery, 
in  marked  distinction  from  the  simplicity  of  the  earlier  forms,  has  resulted 
in  a  division  of  labor  which  has  greatly  increased  the  speed  and  monotony 
of  work  and  tends  to  bring  on  a  fatigued  condition.  Authorities  have  shown 
that  the  wastes  of  the  body,  which  under  normal  conditions  of  work  and  exer- 
cise would  be  thrown  off,  under  conditions  of  overwork  and  exhaustion  are 
allowed  to  accumulate  in  the  blood  and  the  worker  is  literally  poisoned  by 
these  waste  products  and  predisposed  to  specific  ailments  as  well.  This 
condition  also  increases  the  danger  of  contracting  those  definite  occupational 
diseases  which  threaten  many  industrial  workers. 

The  movement  toward  protective  legislation  has  been  greatly  stimulated 
by  the  significant  increase  during  the  last  30  years  in  the  number  of  females 
industrially  employed  in  this  country.  In  1880  this  number  reached  over 
2,500,000;  in  1900  the  number  rose  to  over  5,250,000  and  in  1910  the  number 
had  grown  to  8,075,772,  or  21  per  cent,  of  the  entire  gainfully  employed 
population.  Upon  the  basis  of  the  census  we  find  that  the  number  of  female 
breadwinners  is  increasing  faster  than  the  number  of  male  breadwinners,  and 
also  much  faster  than  the  female  population. 

Females  16  years  of  age  and  over  represent  about  25  per  cent,  of  the  total 
number  employed  over  that  age  and  are  distributed  as  follows: 

Agriculture 1,807,050 

Domestic  and  personal  service 2,620,857 

Manufacturing  and  mechanical 1,772,095 

Mining i,o94 

Trade  and  transportation 1,502,352 

Professional 673,418 

831 


832  LEGISLATION    AND    GOVERNMENT    STUDY 

While  the  proportion  of  women  to  men  in  the  manufacturing  and  me- 
chanical industries,  which  most  concern  us  here,  has  remained  since  1899 
the  same — that  is,  19.5  per  cent. — the  total  number  of  women  has  increased, 
and  in  certain  of  the  larger  industries  it  has  increased  faster  than  the 
number  of  men.  Among  these  industries  are  boots  and  shoes,  canning 
and  preserving,  confectionery,  printing  and  pubhshing,  silk  and  silk  goods, 
tobacco,  and  woolen  and  worsted  goods.  Among  those  industries  where 
the  number  of  women  is  apparently  increasing,  but  not  at  so  rapid  a  rate  as 
the  men,  are  cotton  goods,  men's  and  women's  clothing,  hoisery  and  knit 
goods,  and  miUinery  and  lace  goods.  A  smaller  industry  in  which  the 
number  of  women  is  increasing  not  only  very  rapidly  but  also  much  more 
rapidly  than  the  number  of  men  is  the  manufacture  of  electrical  machinery, 
apparatus  and  suppUes.  Here  the  number  of  women  over  16  increased 
from  6,956  in  1899  to  19,831  in  1909 — an  increase  of  185  per  cent.;  the  number 
of  men  in  the  meantime  increased  only  93  per  cent.  Men  still  form  76  per 
cent,  of  the  total  number  employed  but  this  represents  a  decrease  from  the  82 
per  cent,  employed  in  1899,  while  the  proportion  of  women  to  the  total 
number  employed  has  increased  from  16  per  cent,  to  22  per  cent. 

The  necessity  for  control  over  women's  work  is  now  generally  accepted 
in  this-  country,  both  by  legislators  and  by  the  courts.  This  acceptance  has 
been  secured  because  of  the  emphasis  which  has  been  placed  upon  the  need 
of  protecting  the  health  of  women.  ^  As  Justice  Brewer  said  (Miller  vs. 
Oregon,  208  U.  S.  412) :  "That  woman's  physical  structure  and  the  perform- 
ance of  maternal  functions  place  her  at  a  disadvantage  in  the  struggle  for 
subsistence  is  obvious.  This  is  especially  true  when  the  burdens  of  mother- 
hood are  upon  her.  Even  when  they  are  not,  by  abundant  testimony  of  the 
medical  fraternity,  continuance  for  a  long  time  on  her  feet  at  work,  repeating 
this  from  day  to  day,  tends  to  injurious  effects  upon  the  body,  and  as  healthy 
mothers  are  essential  to  vigorous  offspring,  the  physical  well-being  of  woman 
becomes  an  object  of  public  interest  and  care  in  order  to  preserve  the  strength 
and  vigor  of  the  race." 

In  regard  to  legislation,  however,  concerning  those  occupations  in  which 
the  employment  may  directly  produce  disease,  we  find  ourselves  far  behind 
European  countries.  Practically  no  thoroughgoing,  extensive  investigations 
of  the  specific  occupational  diseases  among  women  workers  have  been  made 
in  this  country.  Indeed  it  has  been  only  within  the  last  few  years  that  the 
subject  here  has  been  widely  discussed  at  all.  It  is  mainly  because  of  this 
l^ck  of  public  information  and  interest  that  we  find  special  legislation  on  this 
subject  in  America  so  meager. 

/  Control  over  woman's  work  is  secured  by  three  main  methods.  The 
first  is  prohibition,  by  which  women  are  entirely  excluded  from  certain 
occupations  which  present  unusual  danger,  such  as  the  use  of  poisons,  ex- 
cessive dusl  or  very  high  temperatures.  The  second  method  is  regula- 
tion, by  which  conditions  in  work  places  must  conform  to  certain  specified 


THE    HEALTH    OF    WOMEN   WAGE   EARNERS  833 

minimum  standards  before  women  may  be  employed  therein.  Regulations 
relate  usually  to  air  conditions,  sanitary  conditions,  temperature,  or  hours 
of  labor.  The  third  method  is  insurance,  by  which  more  adequate  pro- 
tection is  afforded  workers  through  the  action  of  the  employer  who  for 
economic  reasons  desires  to  reduce  costs  due  to  compulsory  compensation  for 
industrial  accidents  or  sickness. 

Before  entering  upon  the  details  of  specific  legislative  enactments  at- 
tention should  be  given  to  the  difference  which  exists  between  the  European 
method  of  establishing  protective  regulations  and  that  employed  in  America. 
Here,  for  legislative  purposes,  we  as  a  rule  group  many  industries  together, 
as  manufacturing,  mercantile  or  transportation.  But  in  Europe,  for  the 
more  important  legislation,  each  particular  industry  is  studied  by  itself 
and  rules  are  provided  to  fit  the  peculiar  dangers  of  that  industry.  In 
addition,  if  any  occupation  or  process  within  the  industry  holds  special 
dangers,  special  rules  are  made  to  apply  for  that  occupation  or  process  alone. 
Thus  in  France  women  and  children  are  excluded  from  a  list  of  over  100 
occupations  unless  certain  regulations  are  complied  with,  and  they  are  en- 
tirely excluded  from  an  additional  list  of  over  50  dangerous  trades. 

The  method  of  administration  in  Europe  also  differs  considerably  from 
that  in  America.  In  foreign  countries  a  general  law  is  usually  accompanied 
by  the  authority  to  make,  through  administrative  orders,  rules  and  regula- 
tions for  each  separate  industry  or  occupation  as  the  needs  of  the  industry 
or  occupation  may  demand,  including  also  the  power  .to  make  limited  ex- 
ceptions. This  applies  to  the  limitation  of  hours  of  work  as  well  as  to  the 
regulation  of  physical  conditions.  Until  recent  years  in  America  all  pro- 
tection was  secured  through  legislative  enactment  alone,  with  considerable 
discretionary  power  in  the  hands  of  the  inspection  officials.  Within  very 
recent  years  several  American  states,  notably  California,  New  York,  Oregon, 
Pennsylvania  and  Wisconsin,  have  enacted  labor  legislation  based  upon  the 
method  used  in  Europe,  and  used  in  America  for  many  years  by  public  service 
commissions  and  by  boards  of  health. 

Having  in  mind,  therefore,  the  European  method  of  enacting  protective 
legislation,  one  is  not  surprised  at  finding  the  factory  acts  of  those  countries 
a  mass  of  detail  frequently  applying  only  to  one  industry,  one  occupation 
or  one  process,  containing  many  exceptions  and  in  most  cases  providing  for 
special  orders  by  the  administrative  authorities. 

PROHIBITED  EMPLOYMENTS 

In  taking  up  the  first  method  of  control  over  woman's  work  we  find 
that  practically  all  civilized  countries  have  recognized  that  certain  employ- 
ments, because  of  unusual  physical  or  moral  dangers,  should  be  closed  to 
women,  and  they  have  given  legal  sanction  to  such  exclusion.  In  America 
most  of  these  prohibitive  laws  relate  to  mines  and  saloons.  Women 
53 


8^4  LEGISLATION   AND    GOVERNMENT   STUDY 

are  forbidden  to  work  in  mines  in  most  of  the  mining  states  and  in 
saloons,  unless  they  are  members  of  the  family,  in  about  i6  states. 
The  employment  of  women  is  forbidden  also  in  a  few  states  in  cleaning 
moving  machines  and  in  the  use  of  emery,  polishing  or  buffing  wheels  where 
articles  of  iridium  or  of  the  baser  metals  are  manufactured. 

Effective  legislation  of  this  character,  however,  presupposes  careful 
intensive  investigation  and  very  few  such  investigations  have  been  made 
in  this  country;  they  are  particularly  lacking  for  the  more  dangerous  occupa- 
tions such  as  those  involving  the  use  of  poisons  or  the  presence  of  harmful 
dusts  or  gases.  We  find  ourselves,  therefore,  far  behind  European  countries 
in  this  particular.  Take,  for  example,  the  one  instance  of  the  use  of 
lead.  The  harmful  effects  of  contact  with  this  poisonous  substance,  and 
particularly  the  pecuHar  susceptibility  of  women,  have  long  been  known. 
In  America^  women  employed  in  lead  processes  in  potteries,  for  example, 
are  engaged  usually  in  dipping  the  ware  in  the  lead  glaze,  removing  the 
excess  glaze,  decorating  with  lead  colors  and  cleaning  or  sweeping  floors, 
boards  or  tables  where  lead  dust  is  present.  Investigations  have  shown  that 
among  women  employed  in  potteries  in  America  the  ratio  of  cases  of  lead 
poisoning  is  i  to  7,  while  in  Great  Britain  the  ratio  is  i  to  64.  Yet 
in  only  six  states  are  there  any  protective  regulations  and  in  no  state  are 
women  excluded  from  work  involving  the  use  of  lead.  Abroad,  however, 
this  prohibition  is  placed  with  more  or  less  thoroughness  upon  women  and 
children  in  many  countries,  including  Argentina,  England,  Germany,  France, 
Italy  and  Holland. 

Among  the  other  occupations  involving  the  use  of  poisonous  substances 
and  forbidden  to  women  in  various  countries  are  the  making  of  electric  ac- 
cumulators, the  manufacture  of  paints,  varnishes  and  colors,  brass  casting, 
zinc  or  lead  smelting,  certain  parts  of  glass  manufacture,  the  manufacture  of 
explosives,  the  curing  of  skins  or  fur  of  rabbits,  and  many  other  occupations 
involving  the  use  of  injurious  chemicals.  Most  foreign  countries  also  pro- 
hibit the  underground  work  of  women  in  mines.  In  France  a  list  of  over 
100  occupations  is  entirely  forbidden  to  women  and  to  children  under  18, 
including  such  occuptions  as  lace  bleaching  with  white  lead,  curing  the 
skins  or  fur  of  rabbits,  sharpening  or  polishing  metals,  coating  mirrors  with 
quicksilver,  and  the  cutting  or  tearing  of  rags.  Twelve  more  employ- 
ments are  forbidden  entirely  to  children  under  18,  and  an  additional  list  of 
occupations  in  which  these  persons  may  not  engage,  unless  certain  harmful 
conditions  are  removed,  includes  establishments  for  bleaching  cloth,  straw  or 
paper,  rubber  works  where  fumes  of  sulphide  of  carbon  are  given  off,  and 
print  cloth  factories,  dye  works,  and  metal-lacquering  establishments  where 
poisonous  substances  are  used.  Spain  has  a  well-classified  list  of  over  100 
occupations  forbidden  to  children  under  16  and  women  under  age.  Similar 
lists,  while  not  identical,  are  found  in  the  more  important  countries.  In  most 
of  these  countries  the  administrative  authorities  are  given  power  to  extend 


THE    HEALTH    OF    WOMEN    WAGE    EARNERS 


835 


the  lists  of  prohibited  employments  at  any  time  that  investigation  reveals  the 
necessity  for  exclusion. 

REGULATED  EMPLOYMENTS 

It  is  seen  that  the  majority  of  the  occupations  which  are  forbidden  to 
women  in  Europe  involve  the  presence  of  dusts,  fumes,  vapors,  gases,  or 
substances  qf  a  poisonous  or  well-defined  harmful  character.  There  exists, 
in  addition,  a  large  group  of  occupations  where  injurious  substances  or 
conditions  are  present  but  where  the  ill  effects  upon  health  are  less  definite. 
This  second  and  much  larger  group  comprises  those  occupations  which 
expose  workers  to  such  harmful  conditions  as  extremes  of  heat  or  cold, 
undue  humidity,  impure  air,  insufficient  or  poorly  distributed  lighting, 
or  excessive  speed  or  strain.  While  these  conditions  produce  a  marked  effect 
upon  the  health  of  women,  predisposing  them  to  such  diseases  as  pneumonia, 
tuberculosis,  functional  and  nervous  disorders,  eye  injuries  or  orthopedic 
derangements,  yet  it  is  difficult  to  designate  sicknesses  of  this  character  as 
specifically  occupational  in  origin,  since  conditions  outside  the  work  place 
may  be  a  factor  in  producing  the  illness. 

The  control  of  conditions  in  occupations  of  this  class  is  usually  effected 
by  means  of  regulations  either  directly  specified  in  the  laws  or  issued  by 
the  administrative  authorities  as  rules  or  orders.  In  America  legislation  of 
this  class  is  extremely  general  in  character,  is  loosely  drawn,  and  seldom 
amounts  to  more  than  a  mere  declaration  of  principles.  Such  laws  apply 
usually  to  all  industries  and  relate  to  adequate  ventilation,  proper  toilet 
facilities,  cleanliness,  lighting,  overcrowding,  and  seats  for  females.  These 
measures  in  most  cases  apply  to  both  sexes  ahke  and  depend  for  their  en- 
forcement almost  entirely  upon  the  spirit  and  intelligence  of  the  adminis- 
trative authorities.  They  are  to  be  found  in  all  of  the  industrial  states  of 
America. 

In  a  very  few  cases  more  specific  provisions  are  found,  as  in  New  York 
where  females  may  not  be  employed  in  connection  with  core  making  in  any 
brass,  iron  or  steel  foundry  unless  the  room  where  cores  are  baked  is  separated 
from  the  making  process  by  partitions  extending  from  the  floor  to  the  ceiling 
and  so  constructed  as  to  prevent  the  passage  of  gases  and  fumes  into  the  room 
where  the  women  are  working.  The  State  Board  of  Labor  and  Industries 
in  Massachusetts,  also,  may  make  regulations  for  the  control  of  work  in  core 
rooms,  and  a  few  states  provide  for  additional  cleanliness  and  toilet  facilities 
where  women  are  employed. 

The  lifting  of  heavy  weights  is  regulated  in  only  one  state,  Massachusetts, 
where  pulleys  or  castors  must  be  provided  for  moving  packages  or  re- 
ceptacles 75  lb.  or  more  in  weight  which  are  handled  by  females;  no 
classification  as  to  age  is  made  and  the  act  applies  only  to  manufacturing 
or  mechanical  establishments. 


836  LEGISLATION   AND    GOVERNMENT    STUDY 

In  a  few  additional  states  specific  regulations  have  been  adopted  which 
apply  to  men  and  women  alike,  as  in  Massachusetts  where  the  relation  of 
humidity  to  temperature  in  textile  mills  is  regulated,  in  New  Jersey, 
Michigan  and  -Illinois  where  specific  rules  exist  for  dust  removal,  and  in 
Wisconsin  where  very  extensive  regulations  have  been  promulgated;  yet 
the  instances  cited  above  practically  exhaust  the  special  protective  regula- 
tions for  women  in  this  country. 

In  contrast  to  these  prevailing  vague  general  provisions  applying  to  both 
sexes  alike,  we  find  in  Europe  detailed  regulations  as  to  temperature,  humidity, 
lighting,  and  the  lifting  of  weights,  applying  to  women  and  minors  alone.  In 
regard  to  the  important  factor  of  temperature  in  workrooms,  we  find  specific 
regulations  in  many  countries.  In  Holland,  for  instance,  women  and 
young  persons  under  16  years  of  age  may  not  be  exposed  to  a  temperature 
of  SlVo"^-  if  ^^6  outside  temperature  is  below  52^-^°?.  in  the  shade;  if  the 
temperature  is  523^^°?.  in  the  shade  or  higher,  the  inside  temperature  may 
not  exceed  this  by  more  than  5%°F.  They  may  not  be  employed  where 
the  temperature  is  continuously  from  45°  to  57^^°F.  unless  the  measures 
prescribed  by  the  district  inspector  of  labor  for  lowering  the  temperature 
have  been  adopted;  neither  may  they  be  employed  in  any  place  which  is  not 
heated  to  i8°F.  or  any  higher  temperature  which  the  district  inspector  may 
require,  particularly  if  the  employees  are  to  do  work  which  requires  little 
physical  exertion.  In  addition,  special  requirements  as  to  temperature  and 
humidity  are  placed  upon  special  processes;  in  spinning  or  weaving  es- 
tablishments, for  instance,  if  the  atmosphere  isartificially  dampened,  a  wet-bulb 
thermometer  must  be  provided  and  the  temperature  may  not  exceed  45°F. 
unless  the  outside  temperature  exceeds  57%°F.  in  the  shade,  in  which  case 
the  inside  temperature  may  vary  in  the  same  proportion  as  the  outside 
temperature.  Experts  in  this  country  might  disagree  upon  the  exact  degree 
of  temperature  to  be  allowed,  but  as  yet  we  have  not  even  taken  steps  for 
regulations  of  any  kind. 

In  Holland,  also,  we  find  special  provisions  in  regard  to  proper  lighting. 
Women  and  young  persons  under  17  may  not  be  employed  in  places  which  are 
insufiiciently  lighted  or  where  artificial  light  is  required  between  9  A.M.  and 
3  P.M.  unless  the  nature  of  the  work  done  makes  it  impossible  to  admit  light, 
in  which  case  the  hours  of  work  may  be  regulated  by  the  administrative 
authorities  and  every  such  person  must  be  given  a  certain  number  of  hours 
each  day  in  the  sunhght.  In  addition,  the  illumination  must  equal  at  least 
30  Hefner  units  at  a  distance  of  i  meter  in  the  following  occupations:  em- 
broidering, weaving  damask,  silk  or  cotton  colored  materials,  the  treatment  of 
diamonds  or  other  precious  stones,  glass-cutting,  engraving  or  wood-cutting, 
instrument  making,  lace  working,  bead  threading,  typesetting,  machine 
knitting,  gold  and  silversmith's  work,  making  of  hair  goods,  sewing,  quilting 
(except  leather  quilting),  drawing  (designing),  and  the  manufacture  or  repair 
of  clockwork.     In  all  other  kinds  of  work  the  illumination  must  equal  at 


THE    HEALTH    OF    WOMEN    WAGE    EARNERS  837 

least  20  Hefner  units  at  a  distance  of  i  meter.  Workers  must  also  be  pro- 
tected from  glaring  light. 

While  we  found  only  one  American  state,  Massachusetts,  providing  pro- 
tection for  women  and  young  persons  in  the  matter  of  lifting  heavy  weights, 
such  regulations  are  frequent  in  foreign  countries.  In  France  weights  to  be 
handled  are  regulated  according  to  age  and  to  the  method  of  moving;  women 
over  18  may  not  carry  any  weight  over  25  kg.  nor  move,  on  two-wheeled  hand- 
carts, more  than  130  kg.  (including  weight  of  handcart).  In  Argentina  this 
regulation  is  confined  to  persons  of  both  sexes  under  20  and  weights  to  be 
lifted  or  moved  are  carefully  adjusted  to  the  age  of  the  worker. 

Special  provisions  are  also  frequently  made  in  European  countries  for 
employed  mothers  who  are  nursing  their  children.  Thus  in  Italy  in  establish- 
ments where  at  least  50  women  are  employed  a  special  room  hygienically 
kept  must  always  be  available  for  the  nursing  of  infants,  and  women  using 
this  room  must  be  allowed  at  least  3'^-hour  in  addition  to  the  regular 
rest  periods;  if  women  nurse  their  children  off  the  premises  they  must  be 
allowed  a  full  hour  in  addition  to  the  regular  rest  periods.  In  France  teachers 
and  females  on  the  staff  of  the  Department  of  Posts,  Telegraphs,  and  Tele- 
phones are  granted,  at  the  time  of  childbirth,  a  leave  of  absence  for  2  months 
together  with  full  treatment. 

American  Conditions  Need  Protective  Legislation. — While  it  is  true, 
as  already  stated,  that  specific  health  investigations  have  been  so  rare  in 
this  country  that  competent  data  do  not  exist  for  the  formulation  of  special 
regulations,  yet  sufi&cient  data  are  at  hand  to  indicate  many  industries  which 
threaten  the  health  of  women  and  children.  Among  such  dangerous  callings 
may  be  mentioned  the  manufacture  of  cordage,  twine  and  jute  goods 
in  which  over  17,000  women  and  children  are  employed.  In  this  in- 
dustry many  women  are  frequently  employed  without  adequate  protection 
from  the  steam,  heat  and  wet  of  the  spinning  rooms,  where  the  spray 
and  drippings  frequently  wet  their  clothing  up  to  the  waist  and  where 
pools  of  water,  gathered  on  the  floors,  often  compel  them  to  go  barefoot. 
Among  such  workers,  colds,  rheumatism,  bronchitis,  and  menstrual  troubles 
are  prevalent.  One  of  the  countries  which  have  regulated  conditions  of 
work  in  these  industries  is  England  where  the  rules  require  adequate  dressing 
rooms  for  holding  dry  clothes  and  changing  after  working  hours;  wet  room 
floors  made  of  material  impervious  to  moisture,  which  will  maintain  the  level, 
and  will  not  crack;  splash  boards  for  the  protection  of  the  workers;  and 
trays  or  groovings  in  the  floor  under  the  frames  to  catch  the  drippings  and 
to  drain  off  the  water.  Adequate  ventilating  devices  to  draw  off  the  steam 
are  also  often  required.  In  France,  also,  women  and  children  under  18  may 
not  be  employed  at  the  wet  spinning  of  flax  unless  the  overflow  of  water  is 
properly  removed. 

In  certain  other  processes  of  this  same  industry  a  large  quantity  of 
harmful  dust  is  present,  causing  physical  injury  to  the  workers.     Physicians 


838  LEGISLATION   AND   GOVERNMENT    STUDY 

practicing  among  operatives  in  the  dusty  processes  testify  that  chronic 
bronchitis,  asthma  and  catarrh  are  unduly  prevalent.  Other  physicians 
have  found  a  certain  skin  disease  which  they  attribute  to  the  presence  of 
irritating  dusts  or  harsh  oils.  In  France  children  under  18  may  not  be 
employed  in  the  stripping  of  flax,  hemp,  or  jute  where  dust  is  freely  given  off. 

The  difference  between  the  method  of  legal  regulation  as  adopted  in 
Europe  and  that  adopted  in  most  American  states  is  well  illustrated  by  a 
comparison  of  the  English  law  governing  dusty  work  of  this  kind  with  that 
of  Massachusetts  where  a  large  number  of  such  establishments  exist.  The 
Massachusetts  law  merely  authorizes  the  inspector  to  require  the  use  of 
a  fan  or  some  mechanical  means  of  ventilation  if  he  thinks  injurious  dusts 
are  present  and  are  inhaled  in  a  harmful  degree,  and  if  such  device  will  not 
entail  an  unreasonable  expense  to  the  employer. 

The  English  law  requires  that  in  every  room  in  which  roughing,  sorting, 
hackling,  preparing  or  carding  of  flax  or  tow  is  carried  on,  efiicient  exhaust 
and  inlet  ventilation  shall  be  provided  to  draw  away  the  dust  from  the 
workers,  at  or  as  near  as  possible  to  the  point  at  which  it  is  generated.  The 
sectional  area  of  the  exhaust  openings  near  to  each  set  of  hackles  must  be 
not  less  than  120  sq.  in.,  and  the  arrangement  must  be  such  as  to  secure  a 
velocity  of  the  air  passing  through  each  exhaust  opening,  and  measured  at 
that  point,  which  at  any  time  is  not  less  than  450  lin.  ft.  per  minute.  The 
air  inlet  must  be  so  managed  that  no  direct  draft  falls  upon  the  persons 
employed,  and  the  arrangement  of  inlet  ventilation  must,  as  far  as  practicable, 
be  such  that  the  temperature  of  the  incoming  air  shall  not  be  less  than  6o°F. 

Investigations  of  the  federal  Bureau  of  Labor  Statistics  have  also  given 
data  on  unhealthful  occupations.  An  illustration  of  such  conditions  is  found 
in  the  glass  industry  which  employes  nearly  10,000  women  over  16  years  of 
age  in  certain  departments. 

In  the  making  of  incandescent  lamps,  we  find  examples  of  extreme  speed 
nd  minuteness  of  work.  In  the  tungsten  department,  for  instance,  in  one 
operation  "the  gossamer-like  tungsten  filament,  which  can  hardly  be  seen 
by  the  untrained  eye,  must  be  inserted  in  a  tiny  hole  punched  in  the  end  of  a 
copper  wire  no  thicker  than  the  finest  needle,  where  it  is  kept  in  place  by 
pinching  the  sides  of  the  wire  together.  This  operation  is  repeated  a  thou- 
sand times  a  day  at  the  rate  of  about  three  every  2  minutes.  Almost 
everyone  has  done  at  some  time  equally  delicate  work,  so  that  the  effects 
which  operations  of  this  nature  must  have  on  the  eyes  and  nerves  can  best 
be  appreciated  by  conceiving  of  the  repetition  of  such  work  through  a  10- 
hour  day  at  a  rate  approximating  that  cited  above."  It  is  pointed  out  that 
without  any  extensive  reduction  in  the  cost  of  materials  used,  a  great  reduc- 
tion in  the  price  of  electric  lamps  has  been  effected  largely  because  of  the 
subdivision  of  processes,  increased  speed  and  the  utilization  of  female  labor. 

In  the  glass  industry  proper,  the  chief  processes  employing  large  numbers 
of  women  and  involving  danger  to  health  are  those  in  finishing  and  decorating 


THE    HEALTH    OF    WOMEN   WAGE    EARNERS  839 

which  consist  mainly  of  polishing,  sand  blasting,  acid  etching,  cutting  the 
glass,  and  painting  and  enameling.  In  sand  blasting,  if  the  apparatus 
is  not  properly  covered,  the  finely  powdered  sand  escapes  through  the  top 
of  the  machine  in  a  forcible  blast,  passes  freely  into  the  room  and  fills  the 
air  while  the  operator  receives  in  the  face  the  full  force  of  the  dust  stream. 
This  dust  is  extremely  fine  and  hangs  suspended  in  the  air  for  a  considerable 
time.  The  federal  investigation  revealed  the  fact  that  nearly  all  the  women 
employed  at  this  work  complained  that  the  dust  caused  a  painful  irritation 
'  of  their  eyes  and  throat.  The  inhalation  of  dust  together  with  the  necessity 
for  constant  standing  make  the  work  of  sand  blasting  particularly  harmful 
to  women.  The  process  of  acid  etching,  while  employing  few  women, 
exposes  these  few  workers  to  the  fumes  of  hydrofluoric  acid  which  causes 
violent  irritation  of  the  eyelids  and  conjunctiva,  cold  in  the  head,  bronchial 
catarrh  with  spasmodic  coughing,  sores  on  the  gums  and  mucous  mem- 
brane of  the  mouth,  and  ulcers,  corrosion  and  blisters.  The  investiga- 
tors found  that  in  one  factory  where  women  were  employed  at  this  work 
they  frequently  had  trouble  with  their  eyes,  and  several  former  employees 
had  been  so  badly  injured  by  the  fumes  that  they  were  compelled  to  stop 
work  entirely. 

In  painting  and  enameHng  glassware,  also,  danger  exists  from  the  fine 
enameling  compounds  which  are  dusted  or  sprayed  on  the  glass  and  which 
usually  contain  lead  and  arsenic.  This  fine  dust  is  inhaled  by  the  operatives. 
Women  engaged  in  the  occupation  of  silvering  mirrors  often  work  in  rooms 
where  the  temperature  reaches  io4°F.,.  this  temperature  being  considered 
necessary  for  the  best  results.  Most  of  this  work  is  done  while  standing, 
and  by  w^omen  over  20  years  of  age. 

Beyond  the  most  general  laws,  no  American  state  attempts  to  regu- 
late such  work,  while  in  European  countries  it  is  frequently  controlled  by 
special  rules.  /  In  Italy  women  and  children  may  not  be  employed  at  all 
in  gilding  and  silver  plating,  and  those  under  21  may  not  be  employed  in 
grinding  and  polishing  glass,  nor  in  making  it  opaque  or  corroding  it  with 
hydrofluoric  acid  or  sand  jets,  /in  Holland  women  and  children  may  not 
be  employed  where  excessive  dust  is  present.  ^In  France,  women  and  chil- 
dren under  18  may  not  be  employed  at  the  dry-polishing  of  glass,  nor  in  any 
process  where  dust  is  given  off  freely,  nor  where  poisonous  materials  are 
used.  In  England  women  and  children  may  not  take  their  meals  in  any 
part  of  a  flint  glass  factory  where  grinding,  polishing  or  cutting  is  carried  on. 

The  federal  investigation  indicated  many  other  industries  which  exposed 
women  to  unnecessary  harmful  conditions  and  which  were  not  controlled  by 
legislation  such  as  we  find  in  European  countries.  Among  these  may  be 
mentioned  the  making  of  brassware,  particularly  in  work  in  the  core  rooms 
and  around  the  ovens  which  expose  the  women  to  high  temperature  and 
injurious  fumes;  in  nickel  plating  where  injurious  and  often  poisonous  fumes 
are  present;  in  the  manufacture  of  firearms  and  ammunition  where  mercury 


840  LEGISLATION   AND    GOVERNMENT    STUDY 

in  the  form  of  a  fulminate  is  used ;  in  making  hardware  where  the  lacquer 
involves  the  use  of  lead  and  irritating  volatile  solvents;  in  the  making  of 
saws  and  files  and  polishing  wooden  handles  where  lime,  metallic  and  other 
irritating  dusts  are  present;  in  the  rubber  industry  where  poisonous  fumes 
exist;  in  artificial  flower  and  caHco  cloth  making  where  aniline  dyes  are  used; 
and  in  pearl  button  making  where  ammonia,  pumice  stone  and  hydro- 
chloric acid  are  present. 

Restrictions  upon  Workpeople.— Control  of  woman's  work  by  regulation 
is  also  secured  by  a  second  method — that  of  restrictions  upon  the  workpeople 
themselves.  The  chief  restrictions  at  present  fall  into  four  main  groups: 
limitations  upon  the  duration  of  the  work  period,  restrictions  in  regard  to 
eating  places,  prohibition  of  work  preceding  and  following  childbirth,  and 
the  medical  examination  of  employees. 

Limitations  upon  the  Duration  of  the  Work  Period.^ — After  all  possible 
/  protection  has  been  provided  through  prohibiting  work  in  dangerous  places 
and  by  regulating  the  physical  conditions  under  which  women  may  be  em- 
ployed, experience  has  shown  that  it  is  still  necessary  to  limit  the  number  of 
hours  which  a  woman  may  be  employed  in  a  day  or  a  week.  Unless  this 
is  done,  the  fatigue  resulting  from  excessive  hours  of  work  will  in  time 
undermine  a  woman's  health,  even  under  the  most  sanitary  conditions. 
In  American  states  this  limitation  has  practically  always  taken  the  form  of 
the  same  hour  rate  for  all  industries  to  which  the  law  applies.  In  Europe 
such  inclusive  limitations  are  often  supplemented  by  exceptions  both  above 
and  below  the  limits  of  the  general  law. 
y  Day  and  Week  Limitations. — On  the  question  of  hour  limitations  for  day- 
/  time  work  many  American  states  have  gone  farther  than  the  European 
'  countries.  A  few  western  states  and  the  District  of  Columbia  permit  only 
8  hours  a  day,  while  nearly  a  dozen  more  Hmit  hours  to  9  a  day.  A  larger 
group  of  over  a  dozen  states  permit  10  or  11  hours  a  day,  but  in  many  cases 
the  total  number  of  hours  per  week  must  not  exceed  54  or  56.  In  actual 
operation  this  frequently  means  that  Saturday  afternoon  becomes  a  half- 
holiday,  particularly  in  the  summer  time.  Still  another  group  allows  10 
hours  a  day  and  60  a  week,  while  six  or  eight  states  place  a  9-  or  lo-hour 
hmit  on  day  work  but  place  no  hmit  on  the  hours  per  week;  this  may  per- 
mit full  time  work  for  7  days  a  week.  While  only  a  few  states  restrict 
work  to  6  days  a  week  the  hmitation  by  both  daily  and  weekly  periods 
has  a  tendency  to  ehminate  7-day  work.  It  is,  however,  well  known  that 
violations  of  the  laws  frequently  occur  both  as  to  hours  per  day,  hours  per 
week  and  days  per  week.  At  present  about  half  a  dozen  American  states 
still  have  no  legislation  restricting  the  hours  of  labor  for  women  workers. 

In  most  of  these  state  laws  exceptions  exist  which  permit  overtime  for 
certain  periods,  in  certain  industries  or  under  specified  conditions.  Other 
laws,  such  as  those  in  North  and  South  Dakota  and  Oklahoma  are  so  worded 
as  to  permit  enforcement  only  against  those  employers  who  compel  work  for 


THE   HEALTH   OF    WOMEN   WAGE   EARNERS  84I 

longer  than  the  stated  period,  and  are  therefore  practically  unenforceable. 
American  laws  apply  as  a  rule  to  most  industries  where  women  are  employed. 
European  legislation  respecting  the  hours  of  labor  for  women  presents 
a  mass  of  detail  similar  to  that  found  in  legislation  for  the  control  of  work 
conditions.  While  general  laws  exist  in  most  countries,  hours  in  many 
industries  or  occupations  are  governed  by  special  regulations,  which  may 
grant  a  work  period  either  longer  or  shorter  than  that  stated  in  the  general 
law.  In  many  European  countries,  as  in  several  American  states,  the 
canning  and  preserving  industries,  for  example,  are  permitted  a  longer  work 
day  than  that  allowed  in  the  general  law.  On  the  other  hand,  many  special 
rules  are  found  which  reduce  the  work  period  below  that  stated  in  the 
general  law.  Thus  in  the  canton  of  Berne  no  girl  under  the  age  of  17  years 
may  be  employed  at  a  treadle  machine  for  more  than  3  consecutive  hours 
a  day.  Women  may  be  employed  in  the  work  of  making  paving  stones 
only  by  special  permission,  and  then  the  hours  are  Umited  to  6  per  day. 
Frequently  also  European  countries  fix  in  the  law  the  time  of  the  day  within 
which  working  hours  must  fall.  Thus  in  England  in  textile  factories  em- 
ployment must  fall  between  6  A.M.  and  6  P.M.  or  between  7  A.M.  and 
7  P.M.;  employment  on  Saturdays  must  end  not  later  than  i  P.M. 

Only  one  American  state,  Oregon,  through  its  Industrial  Welfare  Com- 
mission, had  in  191 5  established  for  any  occupation  a  shorter  work  day  for 
women  than  that  stated  in  the  general  law.  A  few  employers  have  volun- 
tarily or  because  of  trade-union  pressure  reduced  hours  below  the  legal 
maximum  set  by  the  state. 
/  Night  Work. — -The  leading  nations  of  the  world  have  recognized  the 
U  physical  and  moral  dangers  of  night  work  for  women  and  have  enacted  laws 
(  prohibiting  such  work  for  given  periods.  Scientific  investigations  everywhere 
have  shown  that  the  work  of  women  at  night  is  exceptionally  injurious. 
Insufficient,  broken  and  irregular  sleep,  lack  of  sunlight,  irregular  meal 
times,  disarrangement  of  the  normal  customs  of  life,  injury  to  eyesight,  in- 
creased chance  of  accidents — all  of  these  factors  combine  to  lower  vitality, 
to  weaken  the  power  of  disease  resistance,  to  produce  impoverished  blood  and 
anaemia,  to  weaken  the  female  reproductive  functions  and  generally  to 
increase  morbidity  and  mortality.  In  addition  a  legal  limit  placed  upon 
night  work  is  a  great  aid  in  enforcing  the  laws  limiting  the  hours  of  work 
per  day. 

\  But  American  states  have  been  slow  to  remedy  this  serious  evil.  The 
movement  here  received  a  decided  setback  when  in  1907  the  New  York 
Court  of  Appeals  declared  unconstitutional  a  law  forbidding  the  work  of 
women  over  21  years  of  age  in  factories  between  9  P.M.  and  6  A.M.  But  in 
1913  New  York  reenacted  her  earlier  law,  placing  the  closing  hour  at  10  P.M. 
and  the  Court  of  Appeals  in  1915  reversed  its  earlier  decision.  The  caseisnow 
pending  in  the  United  States  Supreme  Court,  where  it  is  hoped  that  a  more 
enlightened  public  opinion  will  aid  in  upholding  this  much-needed  protective 


842  LEGISLATION   AND    GOVERNMENT    STUDY 

legislation.  Since  1890  in  Massachusetts  women  have  not  been  permitted 
to  work  in  manufacturing  establishments  between  10  P.M.  and  6  A.M.,  nor 
in  textile  factories  between  6  P.M.  and  6  A.M.  since  1907.  Similar  laws 
prohibiting  night  work  existed  in  191 5  in  Arkansas,  Connecticut,  Indiana, 
Nebraska,  Pennsylvania  and  South  Carolina,  and  in  Oregon,  and  in 
Washington  for  children  only,  by  rulings  of  the  Industrial  Welfare  Com- 
mission. 

On  the  question  of  protection  from  night  work  European  countries 
have  greatly  surpassed  the  American  states.  There  14  of  the  leading 
nations  have  entirely  prohibited  by  international  treaty  the  work  of 
women  between  certain  periods  at  night.  This  treaty  is  the  result  of  a 
conference  called  by  the  International  Association  for  Labor  Legislation  in 
Berne,  Switzerland,  in  1906.  To  this  conference  delegates  were  sent  by 
the  governments  of  Austria,  Belgium,  Denmark,  France,  Germany,  Great 
Britain,  Holland,  Hungary,  Italy,  Luxemburg,  Portugal,  Spain,  Sweden 
and  Switzerland,  and  an  international  convention  forbidding  night  work  for 
women  was  signed  by  all  of  the  14  countries.  By  191 2  all  of  the  countries 
except  Denmark  had  enacted  legislation  embodying  the  provisions  of  the 
convention  and  had  ratified  the  treaty.  By  the  terms  of  this  treaty,  which 
applies  to  women  over  18  years  of  age,  the  14  countries  bind  themselves  to 
allow  to  women  at  least  11  consecutive  hours  of  rest  at  night  and  to  permit 
no  night  work  between  10  P.M.  and  5  A.M. 

In  addition  many  of  the  smaller  states  and  dependencies  have  indicated 
their  adherence  to  the  provisions  of  the  treaty,  while  several  of  the  signatory 
states  have  gone  even  further  than  the  treaty  requirements.  France, 
Belgium,  and  Spain,  for  instance,  have  forbidden  night  work  between 
9  P.M.  and  5  A.M.,  Austria  has  forbidden  work  at  night  between  8  P.M 
and  5  A.M.,  Germany  between  8  P.M.  and  6  A.M.,  and  Holland  between 
7  P.M.  and  6  A.M.  Even  in  India  the  night  work  of  women  is  forbidden  in 
factories  between  7  P.M.  and  5:30  A.M.;  in  Argentina,  between  9  P.M.  and  6 
A.M.  Most  of  these  countries  permit  exceptions  under  certain  conditions, 
particularly  where  the  nature  of  the  materials  used  is  such  that  a  delay  in 
handling  would  cause  great  financial  loss.  In  such  cases,  however,  very  strict 
limitations  are  imposed,  as,  for  example,  in  Holland  where  large  numbers  of 
women  are  employed  in  skewering  herrings,  a  seasonal  trade.  Here  em- 
ployment after  10  P.M.  is  permitted  for  a  limited  number  of  hours  and  for  a 
limited  time.  In  addition,  breaks  in  the  work  must  be  allowed  every  4 
hours,  and  if  any  break  be  less  than  }'i  hour  it  must  be  counted  as  part 
of  the  period  of  employment;- moreover,  hot  coffee  or  some  other  hot  non- 
alcoholic beverage  must  be  supplied  to  the  night  workers  free  of  charge, 
extra  wages  must  be  paid  for  overtime  work,  and  no  woman  may  be  em- 
ployed after  10  P.M.  without  first  securing  a  medical  certificate  stating  that 
her  health  will  not  be  injured  by  such  work.  Elaborate  provisions  for  en- 
forcement also  exist. 


THE   HEALTH   OF    WOMEN    WAGE   EARNERS  843 

Rest  Periods .—\^it\).  the  exception  of  requiring  from  ^  to  i  hour  for  the 
noon  meal  each  day  (or  after  6  or  6)^^  hours'  work),  practically  no  legal  at- 
tention has  as  yet  been  given  in  this  country  to  the  question  of  rest  periods. 
With  the  increasing  speed  and  complexity  of  modern  industry,  entailing  great 
nervous  strain,  short  intervals  of  rest  during  the  morning  and  afternoon 
periods  would  mean  much  both  to  the  physical  welfare  and  to  the  efficiency 
of  the  worker.  In  the  telephone  service,  for  example,  the  nervous  strain  is 
particularly  severe.  A  Canadian  royal  commission,  reporting  in  1907  on  a 
dispute  involving  the  Bell  Telephone  Company,  recommended  that  the  total 
work  period  be  not  longer  than  6  hours  spread  over  a  period  of  from  8  to 
8%  hours;  this  would  allow  for  at  least  three  rest  periods  of  from  3^^  to  i 
hour's  duration.  A  few  American  firms  have  voluntarily  adopted  the  plan  of 
giving  their  employees  a  15-minute  rest  in  the  morning  and  in  the  afternoon 
and  during  this  time  thoroughly  airing  the  workrooms.  This  principle  is 
enforced  by  law  in  several  European  countries.  Thus  in  Italy,  women  and 
children  under  15  years  of  age  who  work  from  8  to  11  hours  per  day  must 
be  allowed  at  least  ij^  hours'  rest  each  day;  if  work  lasts  longer  than  11  hours, 
2  hours'  rest  must  be  given.  In  Belgium,  women  in  fruit  preserving  must  be 
allowed  at  least  15  minutes'  rest  in  every  5-hour  period  of  work  in  addition  to 
the  noon  rest.  In  the  chocolate  and  confectionery  industry,  when  work  lasts 
between  9  and  10  hours  a  second  rest  period  of  at  least  15  minutes  must  be 
allowed,  and  if  the  working  hours  exceed  10,  a  third  rest  period  of  15  minutes 
must  be  granted. 

Annual  rest  periods,  or  vacations  with  pay,  have  been  voluntarily  granted 
by  a  few  firms  in  this  country,  but  such  a  provision  for  private  employments 
has  never  been  incorporated  into  law.  In  the  canton  of  Berne,  Switzerland, 
however,  we  find  the  provision  that  every  woman  who  has  been  employed 
on  time  rates  in  the  same  business  for  more  than  i  year  is  entitled  to  6 
consecutive  holidays  on  pay;  after  the  second  year's  work,  to  8  days;  after 
the  third,  to  10  days;  and  after  the  fourth  year,  to  12  days. 
/  Childbirth  Protection. — The  desirability  of  additional  protection  for 
I  working  women  at  the  time  of  childbirth  has  been  recognized  by  most  Euro- 
pean countries  and  several  outside  of  Europe.  This  protection  consists  of 
I  forbidding  the  work  of  women  for  a  stated  period,  usually  from  2  to  4  weeks 
[  before  and  from  4  to  6  or  8  weeks  after  childbirth.  In  Natal,  South  Africa, 
the  prohibition  applies  for  3  months  after  delivery,  and  in  Ticino,  Swit- 
zerland, for  6  months  after  delivery.  jbnly__fg[ijr  American  states — Con- 
necticut, Massachusetts,  New  York  and  Vermont — have  similar  legislation. 
The  prohibited  period  in  Massachusetts  and  Vermont  is  2  weeks  before 
and  4  weeks  after  delivery,  in  Connecticut  4  weeks  before  and  4  weeks 
after,  and  in  New  York  4  weeks  following  delivery.  It  is  doubtful  if  laws 
of  this  character  are  as  necessary  as  in  many  European  countries  where 
the  employment  of  mothers  with  young  children  is  undoubtedly  more 
common  (see  also  "Insurance"). 


844  LEGISLATION   AND    GOVERNMENT    STUDY 

^  Regulation  of  Eating  Places. — Still  another  provision  for  the  protection 
of  women  is  that  prohibiting  the  eating  of  meals  in  workrooms  where  processes 
are  carried  on  which  involve  the  use  or  presence  of  injurious  or  poisonous 
materials,  dusts  or  fumes.  Women  and  children  in  England  are  especially 
forbidden  to  take  a  meal  or  remain  during  meal  hours  in  glass  works  where 
materials  are  mixed  or  where  flint  glass  is  made,  poHshed,  ground  or  cut; 
in  earthenware  works  where  dipping,  drying  or  china  scouring  is  done; 
where  transfers  are  made;  or  where  the  tinning  and  enameling  of  metal  hollow 
ware  and  cooking  utensils  are  carried  on.  In  addition,  employees  in  such 
work  must  thoroughly  wash  their  faces  and  hands  before  eating,  and  the 
employer  is  required  to  furnish  adequate  soap,  towels,  nail  brushes  and  hot 
and  cold  water.  Such  restrictions  are  found  in  most  countries  and  more 
often  apply  alike  to  both  sexes.  This  is  true  in  America,  where  the  eating 
of  meals  in  workrooms  where  certain  poisonous  substances,  as  lead,  zinc  or 
arsenic  are  used,  is  forbidden  for  all  employees  in  New  York,  IlHnois, 
Missouri,  Pennsylvania,  Ohio  and  New  Jersey.  In  most  countries  or  states 
where  such  prohibitions  exist  the  employer  is  required  to  provide  sanitary 
eating  rooms  for  the  convenience  of  employees. 

Medical  Examination. — Perhaps  one  of  the  most  difficult  things  for  an 
imerican  to  realize  is  the  extent  to  which  medical  inspection  of  employees  is 
)ractised  in  European  countries.     It  is  very  commonly  enforced  for  both 
jnien  and  women  in  the  dangerous  trades.     We  have  seen  that  women  and 
'  young  persons  are  excluded  from  many  of  the  more  dangerous  employments, 
particularly  those  embodying  the  use  or  presence  of  poisonous  substances. 
In  other  occupations,  where  the  workers  are  threatened  with  injury  to  health, 
women  may  not  be  employed  unless  after  a  thorough  medical  examination 
they  are  deemed  to  be  physically  fit.     In  many  industries  such  examina- 
tions must  be  repeated  at  stated  intervals. 

In  the  decoration  of  china  and  earthenware,  for  instance,  women  in 
England  must  be  medically  examined  at  the  beginning  of  employment  and 
once  each  month  thereafter.  A  health  register  is  kept  wherein  is  recorded 
the  facts  concerning  the  examination.  If  a  woman  is  suspended  from 
work  she  must  be  reexamined  before  she  can  return.  In  the  enameling  of 
iron  plates,  if  any  woman  complains  of  illness  which  may  be  due  to  the 
nature  of  her  work  the  employer  must,  at  his  own  expense,  give  an  order 
upon  a  doctor  for  immediate  professional  attendance.  In  this  work  it  is 
recommended  that  light  food,  such  as  milk  and  biscuits,  be  supplied  each 
woman  before  beginning  work  in  the  morning.  Certificates  of  physical 
fitness  are  at  times  required  before  a  woman  may  engage  in  night  work  or 
be  permitted  to  work  overtime. 

In  America  while  employers  have  at  times  voluntarily  established 
medical  examination  of  employees,  yet  special  legal  requirements  for  the 
medical  examination  of  women  do  not  exist.  Women  are,  however,  in- 
cluded with  men  in  the  laws  requiring  monthly  physical  examination  of 


THE   HEALTH    OF   WOMEN   WAGE    EARNERS  845 

all  employees  engaged  in  dangerous  processes  in  Illinois,  Missouri,  New- 
Jersey,  Ohio  and  Pennsylvania.     These  laws  affect  but  few  women,  but 
should  serve  as  a  beginning  for  a  much  wdder  extension  of  this  important 
preventive  measure  in  the  protection  of  women's  health. 
Insurance. — It  has  often  been  found  that  progressive  employers  provide 
\  more  adequate  protection  for  their  employees  than  can  be  secured  by  direct 
1  legislation.     An  illustration  of  such  a  situation  is  found  in  the  extensive 
\preventive  work  which  has  followed  upon  the  enactment  of  insurance  or 
compensation  laws.     Such  laws  offer  an  economic  inducement  to  prevent 
sickness  or  accident,  and  form,  therefore,  the  third  method  of  protection. 
These  insurance  measures  apply  with  but  few  exceptions  to  men  and  women 
alike  and  are  treated  in  detail  elsewhere.     In  passing  it  may  be  said,  how- 
ever, that  women  are  included  in  all  of  the  health  insurance  laws  of  Europe 
— Germany,  Austria,  Hungary,  Luxemburg,  Norway,  Great  Britain,  Russia, 
Roumania,  and  Serbia — and  in  the  accident  compensation  laws  of  all  civil- 
ized countries  and  of   the  33  American  states  which  by  the  end  of  191 5 
had  adopted  accident  compensation. 

In  addition  to  the  ordinary  sickness  among  industrial  w^orkers,  women 
present  a  special  problem — that  is,  illness  at  the  time  of  childbirth.  While 
in  many  cases,  particularly  among  the  working  class  of  European  countries, 
childbirth  is  a  normal  function  causing  disability  for  a  short  period  only, 
yet  all  of  these  countries  have  recognized  the  desirability,  from  the  point  of 
view  of  the  mother,  the  child  and  the  state,  of  granting  special  financial 
aid  at  this  time.  In  Germany  and  Norway  the  female  wage  worker  is 
granted  maternity  benefits  for  6  weeks,  the  period  during  which  she  is  for- 
bidden to  return  to  w^ork.  Hungary  follows  the  same  time  limit,  w^hile  in 
Russia  the  period  is  only  4  w-eeks.  Great  Britain  allows  a  lump  sum  of 
$7.20  to  all  insured  women,  regardless  of  marital  condition,  and  $7.20  to 
wives  of  insured  men,  making  a  total  of  $14.40  for  the  insured  wife  of  an 
insured  man.  Special  mention  must  be  made  of  the  Italian  system  of 
maternity  benefits  established  in  1910.  This  national  compulsory  system 
applies  to  all  women  wage  earners  in  factories  betw^een  the  ages  of  15  and 
50,  and  applies  alike  to  married  and  unmarried  workers.  It  is  supported 
by  contributions  from  the  state  and  from  the  employer  and  employee  who 
contribute  in  equal  amounts.  The  total  amount  of  the  benefit  given  is 
$7.72,  which  in  Italy  aids  greatly  in  assuring  proper  care  of  both  mother 
and  child  at  this  critical  time.  Although  several  American  states  have 
already  prohibited  the  industrial  employment  of  women  for  a  period  before 
and  after  childbirth,  yet  no  form  of  health  or  maternity  insurance  exists 
by  law  in  America,  although  many  voluntary  societies  provide  such  insurance 
for  their  members. 

It  is  apparent  that  in  the  United  States  considerable  progress  has  been 
made  tow^ard  adequate  protection  of  the  health  of  working  women,  yet 
in  many  respects  American  legislation  lags  far  behind  the  legal  protection 


846  LEGISLATION   AND    GOVERNMENT    STUDY 

already  afforded  by  leading  European  countries  to  the  women  who,  with 
slighter  physique,  are  competing  with  men  amid  the  special  health  hazards 
of  modern  industry. 

REFERENCES 

^For  an  excellent  statement  of  the  world's  experience  in  the  effect  of  industry  upon  the 
health  of  working  women  see  Fatigue  and  Efficiency,  by  Josephine  Goldmark,  Russell 
Sage  Foundation,  New  York  City. 

*  Lead  Poisoning  in  Potteries,  Tile  Works,  and  Porcelain  Enameled  Ware  Factories,  Alice 
Hamilton;  M.  D.,  U.  S.  Bureau  of  Labor  Statistics,  Bulletin  No.  104. 


CHAPTER  IV 

THE  EXCLUSION  OF  MINORS  FROM  INJURIOUS  AND  DANGEROUS 

OCCUPATIONS 

EY  OWEN  R.  LOVEJOY.  New  York  City,  N.  Y. 

Professor  Teleky  of  Vienna  University  has  lately  published  his  findings 
as  to  the  effect  of  work  on  the  health  of  wage-earning  children.  His  study 
showed  especially  the  susceptibility  of  working  children  to  tuberculosis,  but 
he  found,  too,  that  the  general  sickness  rate  in  a  given  group  of  children  in- 
creases after  they  have  left  school  for  work.  The  increase  continues  so  that 
in  a  period  of  4  years  it  is  greater  the  fourth  year  than  it  was  the  first.  That 
is,  the  wear  and  tear  of  industrial  life  tells  on  the  children  and  produces 
in  them  physical  ills  that  grow  greater  rather  than  less  as  times  goes  on. 

We  have  all  felt  that  something  like  this  was  true,  but  we  have  not  often 
succeeded  in  getting  it  down  in  black  and  white  as  Professor  Teleky  has  done, 
and  even  with  actual  figures  before  us  it  is  difficult  to  realize  their  full  import. 
To  appreciate  the  physical  effect  of  industry  on  working  children  we  must  see 
the  children;  we  must  regard  our  data  not  merely  as  statistical  but  as  real 
moulding  forces  in  their  lives;  we  must  realize  what  it  means  to  John  Smith, 
a  normal  small  boy  of  14,  to  work  as  a  doffer  in  a  cotton  mill  for  a  year  and 
there  contract  severe  bronchitis  with  a  cough,  anaemia,  and  cotton  fibroid 
pthisis  so  that  at  15  he  is  far  below  normal  and  handicapped.  Nothing 
can  so  vivify  for  us  the  case  of  the  working  child  as  do  the  mere  unvarnished 
facts  published  by  public  health  authorities.  We  find,  for  instance,  reports 
of  such  occupational  injuries  as  these: 

"  Fred ,  age  14,  employed  by ,  manufacturers  of  picture  frames.     Worked 

putting  bronze  on  frames.  Produced  severe  conjunctivitis  of  the  eyes;  throat  coated  with 
bronze  dust;  expectoration  of  green  bronze  matter. 

"  JoTin ,  age  15,  employed  by ,  enameling  and  stamping  company.     Boy 

handled  grease  and  enamel.  Occupational  dermatitis,  severe  irritation  of  skin  of  hands 
and  arms. 

"James ,  age  15,  employed  by ■,  chair  factory.     Worked  sandpapering 

woodwork  adjacent  to  jointers  and  stainers  where  lead  enamel  was  used,  the  fumes  of 
which  produced  symptoms  of  headache,  gastric  pains  and  nausea,  sore  and  pale  gums;  teeth 
affected;  became  pale  and  weak;  metallic  lead  breath. 

"Joseph ,  age  15,  employed  by ,  opticians,  as  apprentice  boy.     Worked 

drilling  and  cementing  in  which  wood  alcohol  is  used.  Fumes  made  boy  sick,  producing 
nausea  and  vomiting,  asthma,  insomnia,  pupils  unevenly  dilated. 

"  Edward ,  age  14,  employed  by ,  cigar  makers,  as  errand  boy.     Fumes 

of  tobacco  produced  symptoms  of  headache,  sick  stomach.  He  became  weak,  with  dilated 
pupils  and  tobacco  pallor — a  clear  case  of  nicotine  poisoning." 

847 


848  LEGISLATION   AND   GOV^ERNMENT    STUDY 

In  another  report  we  read  of  other  injuries  to  children,  this  time  due  to 
machine  accidents. 

"F.  S.,  male,  14,  nail  sticker,  earning  $4  a  week  operating  American  lightening  heeling 
machine.  A  nail  flew  out  of  the  loader  as  nails  were  released.  Injured  boy  attempted  to 
brush  it  off  with  his  finger.  He  was  caught  by  descending  drivers.  Bone  broken  in  fore- 
finger of  left  hand  between  first  and  second  joints.     Flesh  torn  and  cut. 

"F.  K.,  male,  15,  earning  $3.50  a  week  operating  baling  press.  Gearing  wheels  care- 
fully guarded.  Notwithstanding,  he  stooped  and  placed  his  hands  under  the  guard  to  the 
gearing  wheels.  Lacerated  first  finger,  amputation  second  and  third  finger  at  the  first 
joint,  lacerated  middle  finger. 

"M.  C,  female,  14,  earning  $3  a  week,  operating  automatic  cutting  machine.  Was 
waiting  for  work  to  be  given  her  and  took  screw  driver  and  was  scraping  around  with  it; 
she  put  her  foot  on  the  starting  lever  and  drew  in  the  screw  driver,  also  her  finger.  First 
finger  of  left  hand  was  smashed  and  apparnetly  broken  and  was  later  taken  off  at  the  first 
joint." 

These  are  but  a  few  of  the  many  cases  reported,  but  they  force  us  to 
recognize  the  hazards  of  industry  for  the  working  child,  and  we  must  regard 
those  hazards  as  all  the  more  serious  when  we  realize  that  after  all  in  the 
cases  here  cited  the  children  were  not  working  at  what  are  generally  classified 
as  dangerous  trades.  They  were  working  at  occupations  which  we,  in  our 
present  state  of  enlightenment,  have  considered  safe.  To  be  sure,  we  have 
recognized  lead  poisoning  as  one  of  the  most  insidious  of  industrial  diseases, 
but  even  where  we  have  forbidden  children  to  work  at  trades  in  which  lead 
poisoning  is  probable,  we  have  not  realized  that  a  child  working  near  jointers 
and  stainers  using  lead  enamel  may  in  a  comparatively  short  time  be  affected 
by  the  poison.  In  the  same  way,  although  in  our  most  advanced  legislation 
we  have  forbidden  children  to  operate  recognizedly  dangerous  machines,  we 
have  not  realized  that  machines  apparently  safe  may  become  dangerous  in 
the  hands  of  the  untrained  and  immature. 

Until  very  recently  our  efforts  to  protect  the  health  of  working  children 
here  in  the  United  States  have  been  strangely  scattered  and  unscientific. 
Now  with  a  Federal  Children's  Bureau,  an  increasing  number  of  public  health 
boards  ^nd  growing  interest  in  industrial  hygiene  we  seem  to  be  embarked 
on  a  new  era.  The  value  of  the  public  health  board  cannot  be  overestimated. 
The  mere  recital  of  the  subjects  the  State  Board  of  Health  in  Massachusetts, 
for  instance,  was  required  to  investigate  suggested  the  scope  and  power  of 
the  board.    Among  the  subjects  were: 

1.  The  prevalence  of  diseases  dangerous  to  health  in  home,  schoolhouse, 
factory  or  elsewhere. 

2.  Sanitation  of  schoolhouses  and  industrial  establishments.- 

3.  Information  concerning  the  health  of  young  persons  in  factories  at 
their  work,  and  the  influence  of  such  occupation  upon  the  health  of  these 
minors. 

With  such  a  program  it  is  obvious  the  board  of  health  could  make  tremen- 
dous advances  in  the  direction  of  the  better  understanding  and  protection  of 


INJURIOUS    AND    DANGEROUS    OCCUPATIONS  849 

the  child  in  industry  and  of  the  conservation  of  public  health  in  general.  But, 
unfortunately,  the  Massachusetts  Board  of  Health  was  handicapped,  as  Dr. 
William  C.  Hanson  has  pointed  out,  by  the  lack  of  proper  places  for  the  ex- 
amination of  young  persons  and  by  "the  absence  of  authority  to  exclude 
from  factories  young  persons  found  in  ill  health  or  physically  unfit."* 

This  situation  is  typical  of  our  carelessness  and  laxness  in  legislating  for 
the  protection  of  public  health.  We  provide  for  public  health  officers,  but 
we  do  not  give  them  power  enough.  We  aim  to  protect  the  child  from  in- 
dustrial hazards,  but  we  do  not  fully  protect  the  child.  The  essential  point 
of  both  Professor  Teleky's  conclusions  and  the  quoted  medical  reports,  that 
the  organic  differences  between  the  child  and  the  adult  make  safeguarding 
the  working  child  an  entirely  different  problem  from  safeguarding  the  working 
adult,  is  something  we  have  not  sufficiently  emphasized.  If  the  child  is 
peculiarly  susceptible  to  industrial  strain  and  so  to  industrial  injury,  we 
must  make  drastic,  special  regulations  to  prohibit  the  child  from  working 
under  conditions  that  will  inevitably  lead  to  physical  injury.  This  already 
recognized  principle  has  not  yet  been  carried  far  enough  to  be  effective. 
We  have  considered  it  in  connection  with  age  limits  and  hours  of  work,  but 
in  what  seems  to  be  its  most  obvious  application  we  have  not  made  it  effect- 
ive. In  legislating  for  the  exclusion  of  children  from  dangerous  trades  we 
have  been  strikingly  lax. 

There  are  at  present  26  states  in  the  Union  that  make  some  provision 
for  the  exclusion  of  children  under  16  from  dangerous  trades,  and  three  other 
states  besides  12  of  the  26  specify  other  dangerous  trades  in  which  persons 
under  18  may  not  be  employed.  Fourteen  states  prohibit  the  employment  of 
persons  under  21,  or  minors  in  a  few  other  trades  injurious  to  morals  as  well 
as  to  health,  or  affecting  the  safety  of  others.  But  in  most  cases  the  statutes 
are  vague,  there  is  no  uniformity  in  them.  Where  one  state  specifies  simply 
mines  and  quarries  as  dangerous,  the  next  gives  a  long  list  of  carefully  defined 
processes  or  occupations,  and  a  third  prohibits  the  employment  of  children 
*'in  any  occupations  dangerous  to  health  or  morals, "  leaving  the  definition  of 
such  occupations  to  the  enforcing  officials,  and  it  is  worth  while  here  to  note 
that  almost  invariably  when  a  state  has  such  a  loose  statute,  the  machinery 
for  its  administration  is  so  weak  that  the  law  is  practically  a  dead  letter. 

The  only  attempt  at  uniformity  in  such  legislation  in  the  United  States 

is  the  "Uniform  Child  Labor  Law"  drafted  for  the  National  Conference  of 

Commissioners  on  Uniform  State  Laws  in  191 1  by  the  National  Child  Labor 

Committee  and  later  endorsed  by  the  American  Bar  Association.     This  law, 

which  embodies  the  best  provisions  in  various  state  laws,  has  seven  sectionsf 

dealing  directly  with  dangerous  trades.     Children  under  16  are  prohibited 

from  working  in  the  more  obviously  dangerous  trades,  such  as  in  operating 

dangerous  machinery,  on  railroads  and  vessels,  in  occupations  in,  about  or 

*The  Massachusetts  State  Health  Officers  no  longer  have  legal  authority  to  examine 
the  health  of  young  persons  in  factories.     [lid.] 

t  The  text  of  these  seven  sections  is  given  at  the  end  of  this  article. 

54 


850  LEGISLATION   AND    GOVERNMENT    STUDY 

in  connection  with  poisonous  acids,  dusts  or  gases,  in  heavy  building  trades, 
in  mines  or  quarries,  in  bowling  alleys,  pool  or  billiard  rooms,  or  on  the 
stage.  The  State  Board  of  Health  is  empowered  to  determine  from  time  to 
time  whether  any  processes  or  occupations  not  specified  are  dangerous  to 
the  health  of  children  and  to  make  necessary  prohibitions.  Children  under 
18  are  forbidden  to  work  in  or  about  blast  furnaces,  docks  or  wharves,  in 
certain  electrical  work,  in  cleaning  machinery  in  motion,  in  connection  with 
specified  machines,  in  definitely  specified  railroad  and  navigation  work,  in 
connection  with  processes  in  which  explosives  or  phosphorus  are  used,  and 
in  any  distillery,  brewery  or  place  where  alcoholic  liquors  are  sold.  The 
State  Board  of  Health  is  again  empowered  to  determine  whether  other 
occupations  not  specified  are  dangerous  to  these  children  and  to  forbid  their 
employment  where  necessary.  No  person  under  21  may  be  employed  in  a 
saloon  or  barroom  where  intoxicating  liquors  are  sold,  and  no  female  under 
21  may  work  in  mines,  quarries,  coal  breakers,  or  in  oihng  or  cleaning 
machinery  in  motion,  or  where  she  is  compelled  to  stand  constantly. 

This  is  an  inclusive,  strong  law,  not  drastic  enough  to  make  its  passage 
difficult  in  most  states.  Several  states  have  laws  practically  identical  with 
sections  of  it  and  since  it  is  based  on  state  laws  it  contains  nothing  entirely 
new.  It  is  decidedly  the  best  law  we  have  to  offer  here  in  America,  but  even 
in  advocating  it,  we  should  not  regard  it  as  ideal  but  simply  as  the  first 
step  toward  something  better.  Probably  its  best  feature  is  that  it  leaves 
room  for  constant  improvement  by  providing  that  the  State  Board  of  Health 
may  from  time  to  time  determine  whether  any  processes  not  specified  in  the 
law  are  injurious  to  the  health  of  children.  With  our  regulation  of  dangerous 
trades  in  its  present  embryonic  state  there  must  be  plenty  of  room  for  such 
improvement,  but  even  if  we  were  sure  we  had  docketed  and  pigeonholed  all 
dangerous  elements  in  industry  the  more  elastic  the  law  the  better.  The  best 
law  will  rather  name  the  dangerous  element  in  the  work  than  the  specific 
process  or  trade,  so  as  to  permit  of  application  to  any  process  in  which 
the  dangerous  element  occurs,  and  the  Public  Health  Board  must  be  given 
power  to  make  the  application. 

But  there  are  bound  to  be  questions  as  to  the  definition  of  dangerous 
trades  which  must  sooner  or  later  be  answered.  In  some  states,  for  instance, 
work  in  mines  and  quarries  is  not  recognized  by  law  as  dangerous.  Yet  in 
Minnesota  between  1909  and  1912  there  were  224  accidents  in  mines  as  com- 
pared with  112  in  lumbering  and  woodwork,  69  in  contracting,  and  smaller 
numbers  in  other  industries.  If  these  figures  are  representative,  obviously 
mining  is  a  hazardous  trade,  but  not  until  accident  reporting  is  made  effective 
can  we  expect  to  know  what  are  really  hazardous  trades.  For  the  present 
it  is  safe  to  say  that  if  a  trade  is  so  dangerous  that  we  have  to  take  special 
precautionary  measures  to  safeguard  adults  engaged  in  it  or  have  provided 
special  compensation  or  medical  inspection  for  the  workmen,  or  if  accidents 


INJURIOUS    AND    DANGEROUS    OCCUPATIONS  85 1 

are  known  to  be  frequent,  then  that  trade  is  one  from  which  children  must 
be  excluded. 

But  the  question  is,  who  are  "children?"  It  is  necessary  to  fix  an  age 
limit  under  which  young  persons  may  not  be  employed  in  hazardous  occupa- 
tions. The  Uniform  Child  Labor  Law  represents  our  recognized  standard 
of  age  limits.  It  is  based  on  the  principle  that  no  children  under  14  may  enter 
industry  and  that  no  children  under  16  may  enter  any  hazardous  industry. 
Extra-hazardous  trades  it  prohibits  to  children  under  18  as  well  as  any  trades 
in  which  the  safety  of  others  is  dependent  on  the  worker,  and  which  have  a 
morally  injurious  effect.  It  prohibits  certain  other  trades  which  fall  under 
these  last  two  classes  to  persons  under  21,  and  recognizes  the  physical  differ- 
ences between  men  and  woman  by  making  special  prohibitions  for  women 
under  21. 

Reasons  for  these  age  limits  are  easily  understood.  They  represent  our 
ingrained  ideas  of  the  comparative  strength  and  ability  of  children  between 
the  ages  of  14  and  21,  but  there  is  no  reason  for  believing  that  those  ideas  are 
final.  In  fact  there  is  a  growing  feeling  that  children  should  not  be  in  any 
industry  at  all  until  they  are  16.  Professor  Teleky  drew  that  conclusion 
from  the  facts  he  discovered.  He  believes  that  16  is  young  enough  for  any 
child  to  be  employed,  and  he  advocates  the  strict  limitation  of  hours  of  work 
for  children  under  18  and  the  provision  for  education  and  recreation  for  such 
children.  At  a  hearing  of  the  United  States  Commission  on  Industrial  Rela- 
tions in  New  York  in  May,  1914,  several  witnesses  testified  to  their  belief 
that  children  should  not  be  employed  before  they  are  16.  The  head  of  the 
hygiene  department  of  the  New  York  City  Board  of  Health,  who  carries  on 
the  physical  examination  of  children  seeking  employment  certificates,  stated 
emphatically  that  children  of  14  were  not  physically  fit  for  industry.  The 
chief  mercantile  inspector  for  New  York  City  said  that  his  experience  and 
the  testimony  of  merchants  with  whom  he  came  into  contact  made  him 
certain  that  children  of  14  were  not  mentally  capable  of  doing  the  work 
required  of  them  in  mercantile  establishments,  and  that  the  physical  burdens 
they  had  to  bear  were  usually  too  much  for  them.  If  it  is  becoming  apparent, 
as  it  seems,  that  children  should  not  work  at  ordinary  trades  until  they  are 
16,  then  surely  the  age  limit  for  employment  in  hazardous  trades  must  be  18 
at  least,  and  there  is  a  great  deal  to  be  said  for  the  prohibition  of  all  danger- 
ous trades  to  persons  under  21. 

Professor  Teleky's  report  shows  that  the  evidences  of  industrial  strain 
on  children  increase  rather  than  decrease  as  time  goes  on.  Some  of  this 
increase  is,  of  course,  due  to  the  cumulative  effect  of  strain,  but  some  of  it, 
too,  must  be  due  to  the  fact  that  the  children  are  still  in  the  process  of  growth 
which  makes  them  susceptible  to  injury.  Most  children  probably  do  not 
"get  their  growth"  and  wholly  adapt  themselves  to  full  growth  before  they 
are  21.  Therefore  persons  under  21  may  be  considered  as  organisms  still  in 
the  process  of  growth  and  so  unfitted  for  extraordinary  industrial  hazards, 


852  LEGISLATION   AND    GOVERNMENT    STUDY 

and  it  seems  unnecessary  and  contrary  to  the  final  economy  of  public  health 
to  expose  the  immature  to  the  dangers  of  hazardous  occupations. 

It  is  this  final  economy  that  is  our  modern  concern.  The  exclusion  of 
the  immature  from  dangerous  trades  is  the  logical  consequence  of  the  present 
conviction  that  we  must  scientifically  conserve  human  resources.  It  is  not 
merely  "humanitarian;"  it  is  a  scientific  necessity.  The  need  for  the  exclu- 
sion of  the  immature  from  injurious  work,  for  the  medical  supervision  of  all 
workmen  and  for  careful  physical  examinations  for  all  children  both  before 
they  go  to  work  and  while  they  are  at  it  cannot  be  overemphasized  in 
this  country.  Until  such  medical  supervision  is  made  general  we  shall 
not  have  really  gripped  the  problem  of  industrial  hygiene  in  the  United 
States. 

In  the  meantime,  it  is  imperative  that  the  provisions  of  the  Uniform  Child 
Labor  Law,  or  their  equivalent,  be  enacted  in  every  state  in  the  Union,  and 
that  occupational  hazards  for  children  be  studied  and  defined  by  public 
health  agencies.  The  public  must  put  an  end  to  incompetence  or  self- 
interest  in  the  public  health  service.  Medical  associations,  state  boards  of 
health,  physicians  and  experts  in  hygiene — -those  who  best  know  the  facts — 
must  serve  as  pioneers  in  demanding  that  the  public  health  department  shall 
be  elevated  to  its  rightful  place  and  be  made  the  most  important  arm  of  city, 
county  or  state  government.  It  should  be  impossible  in  the  United  States 
for  a  child  of  15  to  contract  lead  poisoning  or  wood  alcohol  blindness.  Even 
John  Smith  with  his  bronchitis,  anaemia  and  cotton  fibroid  pthisis  should  be 
an  exceptional  case  and  not  one  of  many,  as  he  is  to  day. 

Text  of  sections  of  the  Uniform  Child  Labor  Law: 

Section  3. — -No  child  under  the  age  of  16  years  shall  be  employed,  per- 
mitted or  suffered  to  work  at  any  of  the  following  occupations  or  in  any  of 
the  following  positions:  Adjusting  any  belt  to  any  machinery;  sewing  or 
lacing  machine  belts  in  any  workshop  or  factory;  oiling,  wiping  or  cleaning 
machinery  or  assisting  therein;  operating  or  assisting  in  operating  any  of 
the  following  machines:  circular  or  band  saws,  wood  shapers,  wood  jointers, 
planers;  sandpaper  or  wood-polishing  machinery;  wood-turning  or  boring 
machinery;  picker  machines  or  machines  used  in  picking  wool,  cotton,  hair 
or  any  other  material;  carding  machines;  paper-lace  machines;  leather- 
burnishing  machines;  job  or  cylinder  printing  presses  operated  by  power 
other  than  foot  power;  boring  or  drill  presses;  stamping  machines  used  in 
sheet  metal  and  tinware  or  in  paper  and  leather  manufacturing,  or  in  washer 
and  nut  factories;  metal  or  paper  cutting  machines;  corner  staying  machines 
in  paper-box  factories;  corrugating  rolls,  such  as  are  used  in  corrugated 
paper,  roofing  or  washboard  factories;  steam  boilers;  dough  brakes  or  cracker 
machinery  of  any  description;  wire  or  iron  straightening  or  drawing  ma- 
chinery; rolling  mill  machinery;  power  punches  or  shears;  washing,  grind- 
ing or  mixing  machinery;  calendar  rolls  in  paper  and  rubber  manufactur- 
ing; laundering  machinery;  or  in  proximity  to  any  hazardous  or  unguarded 


INJURIOUS    AND   DANGEROUS    OCCUPATIONS  853 

belts,  machinery  or  gearing;  or  upon  any  railroad,  whether  steam,  electric 
or  hydraulic;  or  upon  any  vessel  or  boat  engaged  in  navigation  or 
commerce. 

Section  4. — No  child  under  the  age  of  16  years  shall  be  employed,  per- 
mitted or  suffered  to  work  in  any  capacity  in,  about  or  in  connection  with 
any  processes  in  which  dangerous  or  poisonous  acids  are  used;  nor  in  the 
manufacture  or  packing  of  paints,  colors,  white  or  red  lead;  nor  in  soldering; 
not  in  occupations  causing  dust  in  injurious  quantities;  nor  in  the  manu- 
facture or  use  of  dangerous  or  poisonous  dyes;  nor  in  the  manufacture  or 
preparation  of  compositions  with  dangerous  or  poisonous  gases;  nor  in  the 
manufacture  or  use  of  compositions  of  lye  in  which  the  quantity  thereof  is 
injurious  to  health;  nor  on  scaffolding;  nor  on  a  ladder;  nor  in  heavy  work  in 
the  building  trades;  nor  in  any  tunnel  or  excavation;  nor  in,  about  or  in 
connection  with  any  mine,  coal  breaker,  coke  oven,  or  quarry;  nor  in  assort- 
ing, manufacturing  or  packing  tobacco;  nor  in  operating  any  automobile, 
motor  car  or  truck;  nor  in  a  bowling  alley;  nor  in  a  pool  or  billiard  room;  nor 
in  any  other  occupation  dangerous  to  the  life  and  limb,  or  injurious  to  the 
health  or  morals  of  such  child;  nor  shall  any  child  under  the  age  of  16  years  be 
employed  upon  the  stage  of  any  theatre  or  concert  hall  or  in  connection 
with  any  theatrical  performance  or  other  exhibition  or  show. 

Section  5. — The  state  board  of  health  may,  from  time  to  time,  determine 
whether  or  not  any  particular  trade,  process  of  manufacture  or  occupation, 
in  which  the  employment  of  children  under  the  age  of  16  years  is  not  already 
forbidden  by  law,  or  any  particular  method  of  carrying  on  such  trade,  process 
of  manufacture  or  occupation,  is  sufficiently  dangerous  to  the  lives  or  limbs  or 
injurious  to  the  health  or  morals  of  children  under  16  years  of  age  to  justify 
their  exclusion  therefrom.  No  child  under  16  years  of  age  shall  be  employed, 
permitted  or  suffered  to  work  in  any  occupation  thus  determined  to  be 
dangerous  or  injurious  to  such  children. 

Section  18. — No  child  under  the  age  of  18  years  shall  be  employed,  per- 
mitted or  suffered  to  work  in,  about  or  in  connection  with  blast  furnaces, 
docks  or  wharves;  or  in  the  outside  erection  and  repair  of  electric  \mes;  in 
the  running  or  management  of  elevators,  lifts  or  hoisting  machines;  in  oiling 
or  cleaning  machinery  in  motion;  in  the  operation  of  emery  wheels  or  any 
abrasive,  polishing  or  buffing  wheel  where  articles  of  the  baser  metals  or 
iridium  are  manufactured;  at  switch  tending,  gate  tending,  track  repairing, 
or  as  brakemen,  firemen,  engineers,  motormen  or  conductors  upon  railroads, 
or  as  railroad  telegraph  operators;  as  pilots,  firemen  or  engineers  upon  boats 
and  vessels;  or  in  or  about  establishments  wherein  nitroglycerine,  dynamite, 
dualin,  guncotton,  gunpowder  or  other  high  or  dangerous  explosives  are 
manufactured,  compounded  or  stored;  (13)  or  in  the  manufacture  of  white 
or  yellow  phosphorus  or  phosphorus  matches;  (14)  or  in  any  distillery, 
brewery,  or  any  other  establishment  where  malt  or  alcoholic  liquors  are 
manufactured,  |packed,  wrapped  or  bottled;  (15)  or  in  any  hotel,  theatre. 


854  LEGISLATION   AND    GOVERNMENT    STUDY 

concert  hall,  place  of  amusement,  or  any  other  establishment  where  in- 
toxicating liquors  are  sold. 

Section  19. — -The  state  board  of  health  may,  from  time  to  time,  determine 
whether  or  not  any  particular  trade,  process  of  manufacture  or  occupation, 
in  which  the  employment  of  children  under  18  years  of  age  is  not  already 
forbidden  by  law,  or  any  particular  method  of  carrying  on  such  trade,  process 
of  manufacture  or  occupation,  is  sufficiently  dangerous  to  the  lives  or  limbs 
or  injurious  to  the  health  or  morals  of  children  under  18  years  of  age  to  justify 
their  exclusion  therefrom. 

No  child  under  18  years  of  age  shall  be  employed,  permitted  or  suffered 
to  work  in  any  occupation  thus  determined  to  be  dangerous  or  injurious  to 
such  children. 

Section  20. — No  minor  under  21  years  of  age  shall  be  employed,  permitted 
or  suffered  to  work  in,  about  or  in  connection  with  any  saloon  or  barroom 
where  intoxicating  liquors  are  sold. 

Section  21. — No  female  under  21  years  of  age  shall  be  employed,  per- 
mitted or  suffered  to  work  in  or  about  any  (i)  mine,  (2)  quarry,  (3)  or 
coal  breaker,  except  in  the  office  thereof,  (4)  or  in  oiling  or  cleaning 
machinery  while  in  motion. 

Section  22. — No  female  under  21  years  of  age  shall  be  employed,  per- 
mitted or  suffered  to  work  in  any  capacity  where  such  employment  com- 
pels her  to  remain  standing  constantly. 

Every  person  who  shall  employ  any  female  under  21  years  of  age  in 
any  place  or  establishment  mentioned  in  Section  i  shall  provide  suitable 
seats,  chairs  or  benches  for  the  use  of  the  females  so  employed,  which 
shall  be  so  placed  as  to  be  accessible  to  said  employees;  and  shall  permit 
the  use  of  such  seats,  chairs  or  benches  by  them  in  so  far  as  the  nature 
of  their  work  allows,  and  there  shall  be  provided  at  least  one  seat  to  every 
three  females. 


CHAPTER  V 

THE  WORK  OF  LABOR  AND  HEALTH  BOARDS  AND  OF 
LEGISLATIVE  COMMISSIONS 

BY  CHARLES  R.  HENDERSON,*  Ph.D.,  Chicago,  111. 

The  General  Problem. — To  describe  and  estimate  the  value  of  measuring 
public  administration  in  relation  to  the  combat  with  occupational  diseases. 
The  cooperative  effort  to  reduce  these  evils  requires:  (i)  the  avancement  of 
science  in  this  field;  (2)  the  popularization  of  knowledge;  (3)  the  expression 
of  the  enlightened  judgment  of  the  public  in  the  form  of  law;  (4)  the  es- 
tablishment and  maintenance  of  suitable,  competent  and  efficient  ad- 
ministrative organization. 

The  Scope  of  This  Chapter. — Administrative  organization  and  its 
activities  is  the  special  problem  of  this  chapter,  which  includes  (i)  federal, 
(2)  state,  and  (3)  local  agencies. 

I.  FEDERAL  ACTIVITIES 

The  activity  of  federal  authorities  in  the  interest  of  public  health  rests 
chiefly  on  the  clause  in  the  constitution  which  gives  Congress  considerable 
power  over  the  operations  of  interstate  and  international  commerce,  but  the 
clause  relating  to  the  common  welfare  has  also  had  great  influence.  The 
investigation  of  diseases,  the  production  and  distribution  of  vaccines,  the 
laboratories  for  the  analysis  of  food  stuffs  and  medicines,  and  the  publica- 
tion of  bulletins  of  information  go  beyond  mere  commercial  regulations. 

By  an  act  approved  August  14,  191 2,  the  name  of  the  "Public  Health 
and  Marine  Hospital  Service"^  was  changed  to  the  "  Public  Health  Service," 
and  this  branch  was  authorized  "to  study  and  investigate  the  diseases  of 
man  and  spread  thereof,"  and  to  publish  information  for  the  public.  By  an 
act  approved  August  23,  191 2,  Congress  authorized  the  appointment  of  a 
temporary  "Commission  on  Industrial  Relations,"  one  of  whose  duties  is  to 
inquire  into  matters  relating  to  the  health  of  employees. 

By  an  act  of  Congress  (approved  April  9,  191 2)  the  use  of  poisonous  white 
phosphorus  matches  was  abolished  from  our  country  by  laying  a  prohibitive 
tax  of  2  cts.  per  100  matches. 

The  establishment  of  the  Childrens'  Bureau  (act  approved  April  9,  191 2) 
was  a  significant  and  prophetic  action. 

*  Deceased. 

8S5 


856  LEGISLATION    AND    GOVERNMENT    STUDY 

Another  law  enacted  in  191 2  evidently  rests  partly  in  regard  for  the  health 
of  workmen,  since  it  forbids  contractors  on  federal  contracts  to  keep  men  at 
work  longer  than  8  hours  in  i  day. 

The  Public  Health  Service,  with  its  central  bureau  at  Washington, 
has  as  its  head  the  Surgeon-General,  with  an  Assistant  Surgeon-General 
over  each  of  its  seven  divisions:  personnel  and  accounts,  foreign  and  insular 
quarantine  and  immigration,  interstate  quarantine  and  sanitation,  sanitary 
reports  and  statistics,  scientific  research,  marine  hospitals  and  relief,  mis- 
cellaneous. Up  to  this  time  this  service  has  been  chiefly  occupied  with 
fighting  communicable  diseases  and  epidemics  and  caring  for  seamen.  The 
bureau  has  a  corps  of  450  medical  officers,  50  pharmacists,  with  a  total 
personnel  of  about  2000  persons.  It  seems  probable  that  in  the  future  the 
scientific  investigations  of  this  service  may  be  extended  into  the  field  of  in- 
dustrial hygiene;  in  scientific  investigation  it  has  already  advanced  knowledge 
of  the  subject. 

The  United  States  Bureau  of  Labor  is  an  indispensable  factor  in  the 
combat  with  industrial  diseases. ^ 

Mr.  Verrill,  of  this  Bureau,  has  made  an  ofi&cial  statement  of  the  function 
of  his  office  which  is  cited  here: 

"  Unlike  the  state  factory  inspection  departments  and  the  state  boards  of 
health,  the  Federal  Bureau  of  Labor  is  not  charged  with  the  duty  of  enforcing 
or  formulating  regulations.  Its  functions  are  limited  to  the  work  of  in- 
vestigation and  study  and  the  diffusion  of  information,  but  with  these  limita- 
tions— that  the  duty  is  imposed  on  the  Bureau  of  studying  the  means  of 
promoting  the  material,  social,  intellectual,  and  moral  prosperity  of  the 
working  men  and  women.  It  is  quite  within  its  scope,  therefore,  to  study 
the  subjects  of  accidents  with  a  view  to  the  elimination,  so  far  as  possible,  of 
dangerous  machinery  and  working  conditions,  and  the  introduction  of  pro- 
tective devices,  or  to  the  study  of  factory  processes  and  conditions  with  a 
view  to  eliminating,  restricting,  or  safeguarding  the  use  of  poisonous  and 
injurious  materials,  or  to  study  lighting,  ventilation,  humidity,  the  disposal 
of  dust  or  fumes,  and  the  improvement  of  the  hygienic  conditions  of  the 
working  places. 

"In  the  group  of  reports  relating  to  factory  inspection  and  occupational 
hygiene,  are  included  articles  in  regard  to  the  inspection  of  factories  and  work- 
shops in  this  and  in  foreign  countries.  The  details  in  regard  to  factory 
legislation  and  inspection,  the  regulation  of  working  conditions,  especially 
in  industries  and  occupations  involving  special  dangers,  have  been  the 
subject  of  special  attention.  Special  studies  have  also  been  made  of  the 
mortality  and  morbidity  in  certain  dangerous  occupations  and  of  the  dangers 
to  employees  who,  in  the  course  of  their  work,  come  into  contact  with  certain 
poisonous  materials.  Under  this  head,  of  the  greatest  importance  are  the 
studies  of  phosphorus  poisoning  in  the  match  industry  and  of  lead  poison- 
ing in  the  lead  industry  and  in  the  manufacture  of  pottery,  tiles,  and  porcelain 


THE    WORK    OF   LABOR   AND    HEALTH  BOARDS  857 

enameled  sanitary  ware.  In  all  of  these  industries  investigation  has  dis- 
closed the  existence  of  dangerous  conditions,  most  of  which  may  be  entirely 
eliminated,  or  very  greatly  improved,  without  serious  difl&culty.  All  of 
these  investigations  have  strongly  emphasized  the  fact  that,  by  a  study  of 
working  conditions  in  the  more  dangerous  and  unhealthful  occupations,  the 
methods  and  experience  of  the  best  may  be  available  for  those  factories  where, 
because  of  ignorance  or  because  of  indifference  resulting  from  ignorance,  dan- 
gerous conditions  have  been  allowed  to  continue  without  any  technical  neces- 
sity and  without  any  economical  need."  The  Supreme  Court  of  the  Union^ 
has  become  a  very  vital  factor  in  securing,  interpreting  and  supporting  de- 
sirable legal  requirements  for  the  protection  of  the  health  of  workmen. 
There  is  a  notable  and  encouraging  tendency  of  the  best  courts  to  confirm 
legislation  which  is  not  merely  based  on  "matters  of  common  knowledge" 
but  on  scientific  authority  which  is  always  in  advance  of  "common  knowl- 
edge" and  much  more  exact  and  reliable.  It  is  evident  that  henceforth  the 
studies  and  judgments  of  experts,  where  there  is  a  reasonable  measure  of 
agreement,  are  to  be  made  the  foundation  of  legislative  and  of  judicial 
interpretations  of  state  and  federal  constitutions.  In  this  connection  the 
"legislative  reference  bureau"  of  Wisconsin  is  a  sign  of  promise,  because  the 
information  there  gathered  will  help  to  frame  laws  which  rest  on  that  foun- 
dation which  will  later  endure  the  critical  examination  of  the  highest  judicial 
authorities,  and  exactly  the  same  facts  which  guided  lawmakers  will  be 
available  when  the  test  cases  are  tried.  The  medical  men  and  engineers 
have  here  a  new  and  promising  field  of  service  to  mankind. 

Dr.  Devoto,  of  the  Italian  hospital  for  occupational  diseases  at  Milan, 
generously  and  wisely  showed  the  intimate  and  reciprocal  relations  of  medical 
and  social  science,  when  he  said:  "In  1898  I  had  the  good  fortune  to  read 
that  which  the  learned  and  eminent  sociologist,  Hector  Denis  said,  with  his 
clear  intelligence:  'Physician!  Come  forth  from  your  limited  domain;  go 
to  the  workingmen,  and  in  labor  you  will  find  an  immense  field  of  study.'"* 

2.  STATES 

Legislation:  States. — The  fundamental  legal  requirements  relating  to 
occupational  diseases  are  found  in  the  statutes  of  the  state  and  of  the  federal 
government,  as  interpreted,  in' case  of  disputes  by  the  courts.  These  statutes 
rest  upon  "police  power"  of  government;  that  is  the  exercise  of  public 
authority  "to  secure  the  public  welfare"  by  restraint  and  compulsion 
(E.  Freund,  Police  Power,  pages  3,  7).  The  laws  passed  by  legislatures 
in  the  U.  S.  are  collected  in  the  2 2d  Annual  Report  of  the  Commissioner  of 
Labor  (1907),  Labor  Laws  of  the  U.  S.,  supplemented  by  later  bulletins. 

It  is  not  within  the  scope  of  this  chapter  to  analyze  these  laws  relating  to 
ventilation,  light,  dust  removal,  etc.,  except  so  far  as  concern  the  powers  and 
duties  of  officials  charged  with  enforcement  of  those  laws. 


858  LEGISLATION   AND    GO\rERNMENT    STUDY 

Administration. — i.  State  Boards:  aim,  scope,  powers,  duties. 

There  are  two  types  of  organs  which  deal  with  the  health,  safety  and 
comfort  of  workers:  labor  boards  and  health  boards. 

(c)  Labor  Boards.— This  is  the  prevalent  type.  It  is  found  in  many 
states  of  the  union.  "In  many  of  the  states  having  laws  of  this  class  pro- 
vision is  made  for  their  enforcement  by  means  of  special  officials  or  in- 
spectors, as  labor  bureaus,  factory  inspection  officers,  and  mine  bureaus; 
while  in  others  this  duty  devolves  upon  such  officers  as  are  charged  with  the 
enforcement  of  the  laws  generally. 

"It  need  hardly  be  added  that  in  states  of  the  latter  class  the  laws  are 
usually  inefficiently  enforced.  The  laws  of  the  various  states  differ  in  their 
nature,  some  being  absolute  or  mandatory  in  form,  directing  certain  pro- 
visions to  be  made  under  prescribed  conditions,  while  others  commit 
large  discretion  to  the  inspecting  as  enforcing  officers.  The  latter  laws 
are  open  to  criticism  as  affording  opportunity  for  a  variety  of  standards,  as 
the  judgment  and  disposition  of  the  enforcing  officials  may  vary.  A  law  that 
provided  that,  if  it  appeared  to  the  enforcing  officer  that  the  .  .  .  conditions 
could,  to  a  great  extent,  be  prevented  by  the  use  of  some  mechanical  con- 
trivance, he  should  direct  that  such  contrivance  be  installed  (Cal.  Act  of 
Feb.  6,  1889)  was  declared  void  on  the  ground  that  it  imposed  on  the  in- 
spector, not  the  duty  of  enforcing  the  law  of  the  legislature,  but  the  power  of 
making  a  law  for  the  individuals,  and  enforcing  such  rules  of  conduct  as  he 
might  prescribe,  which  was  an  unconstitutional  delegation  of  legislative  power 
(Schaezlein  vs.  Cabaniss,  135  Cal.  466,  67,  Pac.  755).  At  what  point  the 
line  would  generally  be  drawn  by  the  courts  is  not  clear,  since  much  of  the 
detail  must  of  necessity  be  left  to  the  judgment  and  integrity  of  the  enforcing 
officers;  and  such  expressions  are  quite  common  as  'in  the  discretion  of  the 
chief  inspector'  (Ind.  A.  S.,  Sec.  7087, 1),  'as  the  factory  inspector  may  direct' 
(Conn.  Acts,  1905,  Sec.  13),  'if  it  appears  to  the  inspector  that  such  (injurious 
inhalation  would  be  substantially  diminished'  (Mass.  Acts,  1909,  Ct.  514, 
Sec.  84);  impossible"  (Arms  and  Ayer,  192,  III,  601,  61,  N.  E.  851;  St. 
Louis  Crusol  Coal  Co.,  v.  III,  185,  U.  S.,  293,  22,  Sup.  Ct.  616).  The 
Wisconsin  system  is  instructive  at  this  point. 

Illustrations  may  be  given  of  a  few  of  the  more  elaborate  laws  touching 
industrial  dangers. 

Illinois. — -One  law  requires  the  use  of  blowers  on  metal  polishing  and 
grinding  machinery.  The  "Health,  Safety  and  Comfort  Act"  provides  for 
adequate  ventilation,  both  artificial  and  natural,  lavatories  for  both  sexes, 
the  disposal  of  noxious  fumes,  gases  and  vapors,  proper  temperature  of 
working  rooms,  seats  for  women.  The  "Occupational  Disease  Act"  (in 
force  July  i,  191 1)  requires  employers  to  adopt  reasonable  and  approved 
devices  for  the  prevention  of  occupational  diseases,  especially  when  workmen 
are  exposed  to  poison  by  lead  or  other  poisonous  substances,  or  in  the  manu- 
facture of  brass  or  the  smelting  of  lead  or  zinc.     These  provisions  were  adopted 


THE    WORK    OF    LABOR    AND    HEALTH   BOARDS  859 

as  a  result  of  the  studies  and  report  of  the  Commission  on  Occupational 
Diseases. 

The  chief  factory  inspector  and  his  staff  are  charged  with  the  enforce- 
ment of  the  laws  and  with  the  prosecution  of  all  violations  before  any  magis- 
trate or  any  court  of  competent  jurisdiction  in  the  state.  The  penalty  for 
violating  the  law  or  obstructing  the  inspectors  is  a  fine  for  the  first  offense 
of  Sio  to  $50;  for  later  offenses  $25  to  $200.  When  the  inspectors  discover 
a  violation  of  the  law  they  are  to  notify  the  managers.  The  essential  require- 
ments of  the  law  must  be  posted  up  in  various  languages  in  all  establishments 
covered  by  the  provisions  of  the  act. 

The  department  of  inspection  employs  a  physician  and  a  physician- 
dentist,  both  of  whom  are  employed  daily  in  the  making  of  personal  inspec- 
tions under  the  "Health,  Safety  and  Comfort  Act"  and  the  "Occupational 
Diseases  Act."  The  medical  men  are  engaged  in  original  research;  they  have 
studied,  for  example,  the  effect  of  lead  sulphate  on  animals  (Letter  of  Oscar 
F.  Nelson,  chief  inspector,  Sept.  8,  1913).  The  law  requires  any  licensed 
physician  who  makes  the  physical  examination  (which  is  required  when  men 
are  brought  into  contact  with  poisonous  agencies  or  injurious  processes) 
to  make  an  immediate  report  to  the  state  board  of  health,  and  this  board 
sends  a  copy  to  the  department  of  factory  inspection.  If  the  employers 
neglect  the  required  protective  arrangements,  an  injured  party  or  his  family 
has  a  right  of  action  for  damages  not  to  exceed  $10,000. 

Michigan.^ — The  governor  is  authorized  to  appoint  a  commissioner  of 
labor,  for  2  years.  This  commissioner  of  labor  may  appoint  factory  in- 
spectors and  assistants;  his  duty  is  to  report  on  the  "moral  and  sanitary 
conditions  of  the  laboring  classes  and  the  productive  industries  of  the  state," 
and  he  is  to  inspect  all  work  places. 

The  law  restricts  hours  of  women  and  children;  forbids  unsuitable  em- 
ployments; requires  exhaust  fans  to  remove  dust;  toilet  rooms  and  wash  rooms 
are  to  be  provided;  tenement  house  work  is  regulated;  seats  for  women  are 
required;  ventilation  of  foundries  is  specified;  sanitary  regulations  for  mines 
are  given. 

Complaints  of  neglect  of  law  may  go  to  a  justice  of  peace  or  magistrate. 
Local  boards  of  health  are  to  report  to  inspectors  cases  of  infectious  or  con- 
tagious diseases. 

Missouri. — An  "Occupational  Disease  Law"  has  been  in  force  since 
June  23,  1913.  It  is  the  duty  of  licensed  physicians  to  report  cases  of  such 
diseases  to  the  state  board  of  health  in  duplicate;  one  copy  is  sent  to  the 
factory  inspector  and  one  to  the  superintendent  of  the  factory.  Various 
hygienic  regulations  (wash  rooms,  clothing,  separate  eating  places,  drinking 
water)  are  included  in  the  law.  It  is  the  duty  of  the  state  factory  inspector 
to  inspect  and  enforce  the  regulations,  and  prosecute  violations.  The 
employer  must  post  warning  notices  of  danger. 

Maryland. — A  state  department  of  health  (191 2)  exists.     The  law  (Ch, 


86o  LEGISLATION   AND    GOVERNMENT    STUDY 

165,  Laws  of  191 2)  describes  occupational  diseases;  requires  physicians  to 
report  to  the  state  board  of  health  any  cases  known  to  them.  It  is  the  duty 
of  the  state  board  of  health  to  enforce  the  law;  it  may  call  on  local  boards  of 
health  and  health  officers  for  aid;  and  it  must  report  date  to  chief  of  Maryland 
bureau  of  statistics  and  information  to  be  published  in  annual  report. 

New  York.^ — The  department  of  labor  is  under  the  commissioner  of  labor, 
who  is  appointed  by  the  governor  by  and  with  the  advice  and  consent  of  the 
senate,  with  a  term  of  4  years  in  office.  The  commissioner  appoints  all 
officers,  clerks  and  other  employees  in  the  office.  There  are  three  bureaus 
in  the  department  of  labor:  factory  inspection,  labor  statistics,  mediation 
and  arbitration.  The  bureau  of  factory  inspection  includes  the  chief  factory 
inspector  (first  deputy  commissioner),  i  assistant,  mechanical  engineer, 
superintendent  of  licenses,  medical  inspector  of  factories,  2  tunnel  in- 
spectors, mine  inspector,  8  supervising  factory  inspectors,  85  factory 
inspectors,  i  chief  clerk  and  20  stenographers  and  clerks.  One  medical 
inspector  of  factories  in  a  great  industrial  state  like  New  York  is  manifestly 
at  a  disadvantage.  His  report  for  191 2  shows  an  effort  to  study  various 
industries  with  a  view  toward  classification  of  those  of  a  dangerous  nature, 
and  the  investigation  of  cases  of  occupational  poisoning  reported,  with  the 
hope  of  discovering  the  causes  and  applying  a  remedy.  Chemical  industries 
and  color  works  have  been  investigated.  Laboratories  and  clinics  have  co- 
operated in  the  study  of  lead  and  arsenical  poisoning.  Hygienic  exhibits 
have  been  prepared  for  public  instruction.  A  mechanical  engineer  was 
employed  to  recommend  better  methods  of  ventilation  of  shops  and  the 
removal  of  dust,  fumes,  gases  and  vapors. 

Ohio. — -The  state  board  of  health,  beginning  May,  1913,  has  been  con- 
ducting a  "survey  of  occupational  diseases"  to  secure  a  basis  for  future 
legislation  and  administration.  This  survey  has  been  conducted  by  E.  R. 
Hay  hurst,  M.  D.,  who  was  one  of  the  medical  investigators  of  the  Illinois 
Commission  on  Occupational  Diseases,  under  the  authority  of  the  board. 
The  survey  is  conducted  by  means  of  articles  published  in  the  monthly  bulletin 
and  in  newspapers,  by  lectures  and  traveling  museum  exhibit;  by  distribu- 
tion of  blank  forms  among  physicians  for  reports  of  cases  of  occupational 
diseases;  by  medical  inspection  of  industrial  establishments  to  discover 
cases;  and  by  experimental  work  under  the  auspices  of  the  Ohio  State  Uni- 
versity. Physicians  are  required  by  law  to  report  cases  of  poisoning  from 
lead,  phosphorus,  arsenic,  brass,  wood  alcohol,  mercury  or  their  compounds, 
contracted  as  a  result  of  the  patient's  employment,  within  48  hours  from  the 
time  of  first  attending  such  patient  (law  passed  March  25,  1913).  The  board 
of  health  has  considerable  discretion  in  relation  to  the  forms  of  reports  and 
the  kind  of  information  demanded;  "such  information  as  may  be  reasonably 
required  by  the  state  board  of  health."  This  is  a  special  investigation  con- 
ducted by  a  regular  and  permanent  state  organization. 

The  Ohio  state    board    of    health  has    large    legal   powers:    supervi- 


THE    WORK   OF    L.\BOR   AND   HEALTH  BOARDS  86 1 

sions  of  all  matters  relating  to  the  preservation  of  the  life  and  health  of 
the  people.  ''It  may  make  special  or  standing  orders  or  regulations  for  pre- 
venting the  spread  of  contagious  or  infectious  diseases  ....  and  for 
such  other  sanitary  matters  as  it  deems  best  to  control  by  a  general  rule." 
Violations  of  laws  or  regulations  are  prosecuted  in  the  courts  by  customary 
procedure. 

Provisions  are  made  for  local  boards  of  health  in  cities  and  villages.  The 
trustees  of  each  township  constitute  the  board  of  health  and  they  must 
appoint  a  health  officer. 

Pennsylvania. — An  act  (taking  effect  June  i,  1913)  contains  the  follow- 
ing provisions.  The  department  of  labor  has  for  its  head  the  commissioner 
of  labor  and  industry,  appointed  by  the  governor,  with  consent  of  the  senate. 
The  bureau  of  inspection  has  inspectors  of  four  grades,  and  of  these  some 
must  be  physicians,  with  a  chief  medical  inspector.  A  medical  engineer,  a 
chemical  engineer  and  a  civil  engineer  belong  to  the  corps  of  inspectors. 
The  inspectors  of  the  fourth  grade  shall  constitute  a  division  of  industrial 
hygiene,  which  shall  be  under  the  immediate  charge  of  the  commissioner. 

Massachusetts. — Until  recently  Massachusetts  placed  the  health  in- 
terests of  the  working  people  under  the  supervision  and  authority  of  rep- 
resentatives of  the  medical  profession.  The  state  board  of  health  formerly 
dealt  with  hygienic  control  of  the  shops  as  a  part  of  the  hygiene  of  the  com- 
munity. The  same  agency  which  investigated  the  dangers  of  occupations 
was  seeking  to  control  the  evils  which  arise  in  the  home  and  community  life  of 
the  worker.  The  state  inspectors  of  health  were  in  constant  communi- 
cation with  local  physicians  who  could  give  information  concerning  not 
merely  communicable  but  also  occupational  diseases  (Paper  of  W.  C. 
Hanson,  M.  D.,  15th  International  Congress  of  Hygiene  and  Demography, 
Vol.  Ill,  page  898). 

The  principles  upon  which  the  state  board  of  health  was  proceeding 
have  thus  been  stated  by  one  of  their  inspectors  (15th  International 
Congress  on  Hygiene  and  Demography,  Vol.  Ill,  Dr.  H.  Linenthal,  State 
Inspector  of  Health,  Boston,  page  907).  To  summarize  briefly:  For  the 
prevention  of  the  ill  effects  upon  health  from  industrial  processes  or  con- 
ditions, the  following  measures  should  be  adopted: 

1.  To  collect  complete  and  accurate  data  about  industrial  processes  and  about  condi- 
tions under  which  the  various  industries  are  carried  on. 

2.  To  obtain  more  accurate  and  detailed  information  relative  to  occupation  on  morbid- 
ity and  mortality  records. 

3.  To  instruct  the  medical  student  in  this  important  field  of  preventive  medicine  by  a 
course  of  lectures  on  the  more  important  industrial  processes  and  the  diseases  to  which  they 
give  rise. 

4.  To  place  the  specific  industrial  diseases  on  the  list  of  diseases  notifiable  to  the  central 
health  authority. 

5.  To  examine  periodically  all  workers  in  certain  industries.  These  industries  should  be 
named  by  the  central  health  authority. 


862  LEGISLATION   AND    GOVERNMENT   STUDY 

6.  To  exclude  minors  and  women  from  certain  industries  which  are  designated  by  the 
central  health  authority  as  injurious  to  health. 

7.  To  have  adequate  laws  regulating  sanitary  conditions  and  protective  devices  in  indus- 
trial establishments,  and  to  have  such  laws  intelligently  enforced. 

8.  To  have  the  central  health  authority  issue  regulations  for  certain  dangerous  trades, 
with  instructions  to  employers  and  employees,  showing  them  how  they  may  guard  them- 
selves against  the  ill  effects  of  their  work,  and  to  have  such  instructions  posted  in  the  work- 
rooms. 

9.  To  carry  on  an  extensive  educational  campaign,  both  among  employers  and  em- 
ployees as  to  the  value  of  protective  measures  and  good  sanitary  conditions. 

By  the  law  of  June  10,  191 2,  the  inspection  of  health  conditions  in  shops 
was  placed  under  an  entirely  different  control.  ("An  act  to  establish  a  state 
board  of  labor  and  industries.")  The  new  board  is  composed  of  one  em- 
ployer, one  laborer,  one  physician  and  one  woman.  This  board  appoints  a 
commissioner  of  labor  and  retains  power  to  remove  at  any  time.  It  has 
power  to  investigate  conditions,  hold  hearings,  seek  expert  advice  and  pro- 
secute violators  of  the  law.  The  duties  of  the  boards  of  health  and  of  police, 
so  far  as  they  related  to  industries,  have  been  transferred  to  this  new  body 
which  may  appoint  industrial  health  inspectors  and  assistants.  The  new 
industrial  health  inspectors  are  not  legally  required  to  have  a  medical 
training.  The  medical  inspectors  under  the  state  department  of  health  no 
longer  enforce  the  law  relating  to  health  inspection  in  factories.  They 
have,  however,  opportunity  to  enter  factories,  if  the  state  commissioner  of 
health  deems  it  necessary. 

{b)  The  Industrial  Commission  of  Wisconsin^ — The  Wisconsin  law  differs 
from  other  laws  by  lodging  in  a  state  commission  considerable  legislative  au- 
thority, but  guards  against  abuses  in  various  ingenious  ways.  The  state  law 
expresses  the  general  will  as  to  the  duty  of  the  employers  to  protect  the  life, 
health  and  safety  of  the  employees  and  the  duty  of  the  latter  to  cooperate 
in  carrying  out  the  purpose  of  the  law.  The  Industrial  Commission  is  charged 
with  making  this  general  law  effective.  It  calls  in  scientific  experts  in  hy- 
giene and  engineering  to  establish  standards  for  regulation  of  all  places  where 
productive  processes  are  carried  on.  These  regulations  must  be  "reason- 
able." In  making  the  orders,  which  have  the  form  of  law,  employers  and 
employees  have  a  right  to  be  heard,  according  to  their  special  knowledge  and 
interests.  The  procedure  is  somewhat  slow,  but  when  regulations  are  drawn 
they  express  the  convictions  of  the  persons  affected,  who  are  also  most  in- 
telligent in  regard  to  the  practicability  of  the  requirements  proposed  by  the 
scientific  advisers. 

(c)  Temporary  Commissions  of  states,  created  by  the  legislature  for  a 
particular  exploration,  with  reference  to  legislation  on  the  subject. 

In  states  where  the  great  industry  has  not  been  developed  and  the  evils 
of  accident  and  disease  have  not  been  vividly  felt,  and  where  boards  of  health 
and  of  inspection  have  not  been  established;  or  where  they  are  incompetent 
or  neglectful,  a  special  temporary  commission  may  render  a  valuable  service. 


THE  WORK  OF  LABOR  AND  HEALTH  BOARDS  863 

An  investigation  carried  on  by  legislative  authority  carries  more  weight  than 
one  instituted  by  private  students,  and  their  researches  issue  in  practical 
bills  for  laws  which  give  permanence  to  the  results. 

The  General  Assembly  of  Illinois  in  May,  1905,  authorized  the  governor 
to  appoint  a  commission^  to  investigate  the  subject  of  social  insurance  and 
workingmen's  old  age  pensions  and  to  report  the  draft  of  a  bill.  This  com- 
mission reported  in  1907,  but  the  time  was  not  then  quite  ripe  for  insurance 
legislation;  later  the  study  bore  fruit  in  a  compensation  law.  In  this  report 
that  commission  urged  the  legislature  to  create  another  commission  to  study 
occupational  diseases.  The  governor  was  authorized  to  appoint  a  com- 
mission of  nine  members,  including  the  state  factory  inspector,  the  secretary 
of  the  bureau  of  labor  statistics,  the  president  and  secretary  of  the  state  board 
of  health,  two  reputable  physicians  and  three  other  citizens.  This  com- 
mission organized  a  corps  of  investigators,  made  studies  especially  of  poison- 
ing by  lead,  arsenic,  mercury,  gas  in  foundries,  caisson  diseases,  and  miners' 
exposure  to  disease.  The  report  was  laid  before  the  legislature  in  January, 
191 1.  As  an  immediate  result  the  legislature  extended  the  protective 
measures  to  include  shop  hygiene  (House  Bill,  No.  250,  approved  May  26, 
1911).  In  Illinois  court  decisions  and  tradition  have  rigidly  restricted  the 
power  of  the  legislature  to  delegate  its  functions  to  administrative  bodies; 
and  therefore  it  was  necessary  to  make  the  law  explicit  in  all  the  regulations 
which  the  factory  inspectors  were  required  to  enforce.  In  this  respect  the 
Illinois  method  is  radically  diflferent  from  that  of  Wisconsin;  and  yet  the 
inspectors  were  required  to  act  in  interpreting  what  were  "reasonable  and 
approved  devices"  for  the  prevention  of  occupational  diseases.  Periodical 
medical  examination  of  workmen  exposed  to  lead  poisoning  was  required, 
and  this  clause  introduced  a  new  principle  into  the  law.  Medical  men  were 
for  the  first  time  added  to  the  staff  of  inspectors;  a  laboratory  was  established; 
and  this  factor  has  been  found  helpful  in  detecting  and  averting  danger  to 
health. 

The  New  York  Factory  Investigating  Commission  was  another  example 
of  a  temporary  organization  for  the  exploration  of  conditions.  Its  appoint- 
ment was  due  to  a  tragic  loss  of  hfe  in  connection  with  the  burning  of  a  work 
place.     Engineering  problems  were  primarily  considered. 

Local  Health  Organization — Municipal.^ — The  primary  function  of 
municipal  health  boards  and  commissioners,  according  to  ordinances  pub- 
lished, are  interpreted  to  be  those  relating  to  the  suppression  of  nuisances; 
the  combat  with  communicable  diseases;  notification,  isolation,  disinfection; 
examination  of  school  children;  vaccination;  control  of  barber  shops,  street 
cars,  lodging  houses  and  tenements,  laundries,  wash  houses,  common  drink- 
ing cups,  rags  and  secondhand  goods,  food  stuffs,  milk  and  milk  products, 
housing  and  plumbing,  privies  and  cesspools,  stables  and  disposal  of  ma- 
nure, domestic  animals  and  dead  bodies,  garbage,  refuse  and  ashes,  offensive 
trades,  midwifery  and  lying-in  houses,  births,  marriages  and  interments— that 


864  LEGISLATION   AND    GOVERNMENT    STUDY 

is,  with  matters  of  general  concern.  Only  in  exceptional  regulations  do  we 
discover  as  yet  any  distinctly  conscious  purpose  of  municipal  authorities  to 
study  and  supervise  industrial  estabhshments  and  the  conditions  affecting 
the  health  of  workmen. 

An  interesting  illustration  of  local  voluntary  regulation  of  conditions 
affecting  health  is  the  organization  in  the  garment-working  trades  of  New 
York  City,  where  60,000  to  70,000  persons  are  engaged  in  a  business  whose 
annual  product  is  about  $250,000,000.  In  1910  a  joint  board  of  sanitary 
control  was  organized,  whose  members  represented  employers,  employees 
and  the  public,  and  it  was  given  power  to  estabhsh  standards  of  hygienic 
conditions  and  enforce  them.  They  have  carried  on  medical  examinations 
of  employees,  educated  the  workers  in  the  rules  of  hygiene  and  inspected  the 
provisions  for  light,  safety,  ventilation,  cleanhness,  comfort  and  decency.^" 

Administrative  Law." — Administrative  law,  a  branch  of  public  law,  de- 
termines the  form  of  organization,  gives  authority  and  direction  to  the  oflScers, 
and  protects  both  individual  rights  and  community  interests.  The  legisla- 
ture expresses  the  will  of  the  people  in  general  outline  and  within  the  con- 
stitutional limitations,  but  the  administration  must  carry  out  the  law  in 
detail  through  ordinances,  regulations,  orders,  and  personal  supervision. 

In  both  federal  and  state  governments  duties  are  distributed  between 
central  and  local  officers,  and  the  latter  are  subject,  in  varying  degrees,  to 
superior  supervision,  direction  and  control.  Cities  and  counties  have  only 
such  powers  as  may  be  expressly  conferred  on  them  by  charters  which  en- 
numerate  those  powers,  or  by  laws  of  a  general  scope. 

In  the  United  States  there  is  a  strong  tradition  unfavorable  to  granting 
administrative  bodies  legislative  powers,  and  this  is  at  times  a  cause  of  ineffect- 
ive service.  The  executive  officials  are  bound  by  the  law,  which  often  enters 
into  many  details  not  appropriate  for  general  legislation.  The  theory  is  that 
administrators  and  municipalities  have  closely  defined  powers  and  cannot  go 
beyond  them.  While  the  powers  of  the  President  of  the  United  States  have 
been  enlarged ,  those  of  governors  of  states  have  been  reduced.  As  a  general  rule 
the  heads  of  departments  are  elected  by  the  people  and  are  not  subject  to  the 
control  of  the  governor ;  and,  since  there  is  no  responsible  executive,  public  busi- 
ness frequently  lacks  coherency,  unity  and  efficiency.  The  "  long  ballot "  con- 
tains so  many  names  that  the  voters  know  very  little  about  the  qualifications 
of  their  candidates,  and  an  election  can  hardly  be  said  to  express  the  choice  of 
the  people.  One  of  the  most  serious  defects  of  our  system  is  the  want  of 
central  power  of  supervision  and  control  of  local  administration.  County 
officers  do  much  as  they  please,  while  the  state  board  sends  out  circulars  of 
advice  which  go  unheeded.  In  matters  of  health  the  need  of  central  control 
is  so  obvious  that  greater  authority  is  given  state  boards  of  health,  especially 
in  times  of  epidemic,  and  here  a  larger  measure  of  discretion  is  given  to  medical 
authorities  without  enumeration  of  their  specific  duties  and  powers.  The 
state  factory  inspection  is  relatively  independent  of  local  influence,  and 


THE  WORK  OF  LABOR  AND  HEALTH  BOARDS  865 

can  be  made  uniform,  equitable  and  efficient  in  its  working.  The  great 
danger  is  that  the  inspectors  may  be  products  of  the  "spoils  system," 
unfit  for  their  office,  and  that  they  may  be  bribed  or  otherwise  induced  to 
neglect  the  enforcement  of  the  law.  One  of  the  grave  defects  of  local' 
administration  and  often  of  state  administration  is  that  it  is  not  professional; 
the  term  of  office  is  short  and  uncertain,  and  it  is  impossible  to  acquire  skill. 

Enforcement  of  the  Law. — Usually  the  employers  are  induced  to  obey 
the  law  by  the  orders  of  the  inspectors.  If  they  refuse,  the  inspectors  may 
bring  the  matter  to  the  attention  of  the  prosecuting  attorney  or  the  compe- 
tent court,  and  obedience  is  enforced  by  judicial  authority  sanctioned  by 
the  penal  provision  of  the  statute. 

Information. — One  function  of  administration  is  to  make  records  of  its 
activity  and  publish  information.  The  scientific  test  of  the  actual  working 
of  a  law  and  of  an  office  is  the  result  of  activity,  and  the  evidence  must  be 
supplied  by  those  responsible  for  the  administration.  Laboratories  are 
properly  connected  with  state  and  city  offices,  under  professional  direction, 
first  of  all  to  improve  the  service  to  patients  and  to  persons  exposed  to  danger, 
and  in  the  second  place  for  scientific  investigation. 

Control  over  the  Administration. — The  purpose  of  the  mechanism  of 
control  is  to  promote  efficiency  in  the  service,  to  protect  personal  rights 
against  arbitrary  and  illegal  acts  of  officials,  and  to  further  social  welfare. 
The  modes  of  control  are  administrative,  judicial,  and  legislative.  The  sys- 
tem of  administration  contains  in  its  own  law  and  regulations  instructions 
which  are  designed  to  prevent  unreasonable  and  injurious  actions  of  persons 
armed  with  authority.  There  is  also  an  appeal  to  the  courts  when  a  citizen 
thinks  he  is  wTonged  or  is  in  danger  of  being  injured  by  persons  in  office. 
And  finally  the  law-making  assembly  has  large  powers,  upon  complaint  or 
petition,  to  investigate  any  branch  of  the  administration  and  to  enact  laws 
directing  and  restricting  the  action  of  public  servants. 

REFERENCES 

*  Yale  Review,  1905-6,  page  181.     "  Federal  Activity  in  the  Interest  of  the  Public  Health," 

by  Professor  J.  W.  Garner.  This  article  discusses  the  National  Quarantine,  the 
National  Board  of  Health,  the  Public  Health  and  Hospital  Service,  and  Pure  Food 
Regulation.  Recent  and  official:  "Federal  Public  Health  Administration,"  by 
J.  W.  Kerr,  Assistant  Surgeon  General;  Public  Health  Reports,  Jan.  17,  1913; 
"Organization,  Powers,  and  Duties  of  the  United  States  Public  Health  Service 
To-day,"  by  J.  F.  Anderson,  read  before  the  Massachusetts  Association  of  Boards  of 
Health,  July  31,  191 3;  "Organization,  Powers,  and  Duties  of  Health  Authorities,"  by 
J.  W.  Kerr,  Public  Health  Bulletin  No.  54,  August,  1912. 

'  Verrill,  Charles  H. — "The  Relation  of  the  U.  S.  Bureau  of  Labor  to  Industrial  Hygiene. 
15th  International  Congress  on  Hygiene  and  Demography,  Vol.  Ill,  Part  II,  pages 
714,  916. 

'  Goodnow,  F.  J. — "Social  Reform  and  the  Constitution."  Mrs.  Florence  Kelley: 
"Some  Ethical  Gains  through  Legislation." 

*  II  Congres  de  Maladies  professionnelles,  page  165. 

55 


866  LEGISLATION   AND    GOVERNMENT    STUDY 

» Act  285,  Public  Acts  of  1909  (amended  191 1). 

«  New  York  State  Department  of  Labor;  Ann.  Rep.  of  Commissioner  of  Labor,  191 1  and 

1912.    Law:  Labor  Laws  of  U.  S.,  page  905  (Acts  of  1907),  and  in  Rep.  of  Com.  of 
,        Labor,  191 2. 
^  Since  a  special  chapter  is  given  to  the  Missouri  system,  it  is  not  further  discussed  here. 

See  J.   R.    Commons:  Labor   Administration;  and   15th  International  Congress  on 

Hygiene  and  Demography,  Vol.  III. 
«  International  Congress  on  Hygiene  and  Demography,  Vol.  HI,  Part  II,  page  928. 
•  See  "Municipal  Ordinances,  Rules  and  Regulations  Pertaining  to  Public  Hygiene  (Jan. 

I,  1910,  to  Jan.  30,  1911).     Reprint  from  Public  Health  Reports,  No.  70,  Washing- 
ton, Government  Printing  Office,  191 2. 
1"  Paper  of  Lillian  D.  Wald:  15th  International  Congress  on  Hygiene  and  Demography, 

Vol.  Ill,  Part  II,  page  881. 
11  Freund,  E.— The  Police  Power.    Lowell :  Governments  and  Parties,  1, 44-4.    A.  Goodnow: 

Comparative   Administrative  Law,  127;  Labor  Laws  of  the    United  States  (1907), 

with  subsequent  bulletins  of  the  Bureau  of  Labor. 

BIBLIOGRAPHY 

Public  Health  Reports,  United  States  Public  Health  Service,  Vol.  XXVIII,  No.  17,  April 

25,  1913  (Washington,  D.  C),  contains  a  list  of  the  State  and  insular  health  authorities 

of  the  United  States. 
Freund,  E.— "Police  Power." 

Freund,  E. — Das  offentliche  Recht  der  Vereinigten  Staaten  von  Amerika. 
Goodnow,  F.  J. — Comparative  Administrative  Law. 
Goodnow,  F.  J. — Social  Reform  and  the  Constitution. 
Fifteenth  International  Congress  of  Hygiene  and  Demography,  Section  IV,  Vol.  III.     Part 

11. 
Bulletin,  100  U.  S.  Bureau  of  Labor  (191 2). 
Grotjahn. — Soziale  Pathologie  (page  679). 
Van  der  Borght. — Grundriss  d.  Sozialpolitik. 
Rapmund,  O. — Das  offentliche  Gesundheitswesen  (1901). 
Gallard,  F. — L'Hygiene  de  I'Ouvrier  aux  Etats-Unis  (1905). 
Levasseur,  E. — L'Ouvrier  Americain. 
Public  Health  Bulletins:  No.  54  Organization,  Powers,  and  Duties  of  Health  Authorities. 

J.  W.  Kerr  and  A.  A.  Moll,  Aug.,  191 2. 
Reprints  from  Public  Health  Reports,  No.  109,  Public  Health  Administration.     John  W. 

Trask,  Jan.,  1913.     No.  112,  Federal  Public  Health  Administration,  J.  W.  Kerr,  Jan., 

1913- 


CHAPTER  VI 
EFFECTIVE  LEGISLATION  AND  ADMINISTRATION 

BY  C.  H.  CROWXHART,  LL.  B..  Madison,  Wisconsin. 

SECTION  I 

Principles  of  Legislation.— Legislation  for  safety  of  life  and  limb  has  come 
piecemeal  after  long  experience  has  demonstrated  its  need.  It  has  come 
largely  as  a  remedy  for  a  known  evil  instead  of  anticipating  e\'il  and  pre- 
venting it.  Little  else  could  be  expected  from  the  legislature  created  to  deal 
concretely  with  concrete  things.  Hence,  we  have  legislation  providing  a 
penalty  for  not  guarding  a  bull  wheel,  or  a  buzz  saw,  or  an  emery  wheel; 
we  have  legislation  providing  a  penalty  for  polluting  a  water  supply  in  a 
certain  way,  preventing  sale  of  dirty  milk,  or  contaminating  the  air  with 
smoke;  we  have  legislation  pro\ading  for  the  quarantine  of  certain  enumerated 
diseases,  for  vaccination,  or  for  segregation  of  tuberculosis  patients.  This 
kind  of  legislation,  deahng  with  certain  enumerated  dangers  to  public  life  or 
health,  invariably  comes  with  much  agitation  and  public  pressure  long  after 
scientific  or  expert  men  have  reached  a  full  reaUzation  of  the  need  of  a  rule 
of  safety  on  the  subject.  The  legislative  rule,  when  expressed,  often  fails 
adequately  to  meet  the  situation,  and  naturally  so,  because  the  legislature 
meets  infrequently,  has  many  things  to  do,  is  a  non-expert  body,  and  has 
little  time  to  devote  to  details,  even  though  the  details  may  be  of  vital 
importance. 

For  these  reasons  we  find  that  factory  legislation  in  this  country  has  come 
almost  solely  from  agitation  by  labor  unions.  Such  bodies  are  without 
sufficient  means. to  gather  statistics  and  to  vitalize  facts  for  present  action  to 
legislatures;  nevertheless,  the  labor  unions  have  been  impelled  by  shocking 
instances  of  abuse,  occurring  within  their  sight  and  hearing,  to  present  con- 
vincing facts  to  the  legislatures  against  effective  lobbies  of  employers  who 
saw  the  cost  of  a  proposed  change  but  who  did  not  comprehend  the  ultimate 
benefits.  Thus  there  has  been  very  little  method  in  this  country  in  applying 
scientific  study  or  expert  advice  to  problems  which  the  professional  or  expert 
man  is  most  competent  to  handle. 

In  European  countries  such  matter  have  long  been  dealt  with  through 
administrative  orders,  but  with  us  the  constitutional  power  to  handle  the 
subject  in  this  manner  has  not  been  so  plain.  Within  recent  years  it  has 
begun  to  dawn  on  the  public  that  there  is  really  no  reason  why  the  European 
method    is    not    applicable   in    a   modified    way   in   America.     While   the 

867 


868  LEGISLATION    AND    GOVERNMENT    STUDY 

legislative  power,  by  constitution,  is  given  to  the  legislature,  courts  have 
held  that  the  legislature  may  enact  legislation  to  become  effective  upon 
the  subsequent  determination  of  a  fact  by  another  branch  of  the 
government.  And  the  courts  have  held  that  a  legislative  grant  of 
authority  carries  the  impHed  power  to  do  all  things  necessary  to  make  the 
legislative  intent  fully  effective.  Likewise  the  courts  have  held  that  where 
the  legislature  delegates  power  to  another  body  to  ascertain  a  fact,  courts  will 
not  set  aside  the  findings  of  that  body  unless  the  findings  are  opposed  to  the 
the  fact  beyond  a  reasonable  doubt.  The  method  of  deahng  with  problems 
requiring  expert  investigation  was  first  enacted  into  effective  statutory  law 
in  Wisconsin  by  the  creation  in  1905  of  a  railroad  commission  with  adequate 
powers.  To  this  commission  under  similar  legislation  w^as  given  the  control 
of  public  ultilities  in  1907.  More  or  less  feeble  attempts  were  made  before 
that  time  to  delegate  authority  to  various  boards,  but  no  comprehensive 
plan  embodying  the  European  idea  of  administration  orders  was  enacted 
before  the  Wisconsin  Railroad  Commission  Act  of  1905.  The  Federal  Inter- 
state Commerce  Commission  recently  has  been  given  similar  powers;  railroad 
commissions  and  pubhc  utility  commissions  with  like  powers  have  been 
created  in  many  states.  As  might  be  expected,  the  idea  of  adequately 
protecting  and  regulating  property  rights  anteceded  the  more  human  rights 
of  safety  of  life  and  health.  But  of  recent  years  it  has  become  more  and  more 
apparent  that  we  must  deal  with  the  problem  of  life  saving  in  a  more  rational 
way.  We  are  gradually  beginning  to  see  what  can  be  done  by  expert  treat- 
ment of  this  purely  technical  subject.  The  methods  and  results  of  handling 
the  health  problem  in  the  Panama  Canal  Zone,  for  example,  have  proved  a 
revelation. 

Wisconsin  in  191 1  had  a  vision  of  the  future  for  safety  legislation  as 
applied  to  places  of  employment — the  relation  of  master  and  servant,  to 
use  a  common  law  term,  or  the  relation  of  employer  and  employee,  to  use 
the  modern  expression. 

Under  its  railroad  commission  regulation,  the  Wisconsin  legislature  has 
said  that  every  unreasonable  rate  should  be  unlawful;  then  it  committed  to 
the  commission  the  power  to  find  as  a  fact  the  reasonable  rate.  With  this 
general  rule  went  the  appropriate  administrative  machinery  and  provisions 
for  court  review.  The  same  principle  was  applied  in  191 1  to  safety  in  the 
various  employments  of  the  state.  The  legislature  enacted  the  broad  and 
comprehensive  rule  that  every  place  of  employment  shall  be  reasonably  safe, 
and  safe  is  defined  to  mean  freedom  from  danger  to  the  life,  health  and  com- 
fort of  employees.  The  legislature  then  committed  to  the  industrial  com- 
mission the  power  to  find  the  facts  as  to  safety.  As  in  the  case  of  the  railroad 
commission,  the  facts  are  determined  by  orders  and  under  the  legislative 
scheme  these  orders  have  the  force  and  effect  of  law. 

Under  this  scheme  it  is  plain  to  be  seen  that  the  legislature  has  laid  down* 
a  rule  that  is  good  for  all  time.     What  more  can  be  desired  from  a  safety 


EFFECTIVE    LEGISLATION    AND    ADMINISTRATION  869 

Standpoint  than  that  every  place  of  employment  shall  be  safe,  the  term  "  safe" 
including  physical  decency  and  comfort?  From  then  on  the  problem  takes 
on  the  aspect  of  scientific  and  expert  study,  as  applied  to  each  employment, 
to  find  the  factors  of  safety  and  then  to  incorporate  such  factors  in  the  proper 
order.  Here,  then,  is  the  elastic  basis  of  safety  legislation.  As  science, 
study,  or  discovery  may  open  the  way  to  safer  methods,  the  proper  machinery 
is  at  hand  to  incorporate  such  new  methods  into  law  and  make  them  im- 
mediately effective.  The  advantages  of  this  scheme  of  general  legislation, 
leaving  details  to  be  supplied  by  a  competent  body  of  experts,  are  manifest. 
The  fundamental  rule  is  the  same  all  the  time.  Upon  this  basic  rule  the 
whole  body  of  safety  regulation  grows  day  by  day,  year  by  year,  discarding 
the  dead  as  the  living  body  discards  dead  tissue,  and  taking  on  new  rules 
as  new  ideas  develop  safer  methods.  The  problems  of  safety  have  become 
the  problems  of  education.  No  longer  does  safety  of  life  and  limb  await 
legislative  inaction.  The  whole  subject  has  become  one  of  efiBcient 
administration. 

SECTION  n 

Methods  of  Administrative  Boards.- — The  Wisconsin  commission  is  ap- 
pointed by  the  governor  and  confirmed  by  the  senate.  The  term  of  office  is 
6  years  and  the  individual  salaries  equal  those  of  the  constitutional  state 
officers.  Opportunity  is  afforded  for  obtaining  as  assistants  in  the  field 
and  office  efficient  men  and  women  who  devote  their  entire  time  to  their 
work. 

The  chief  objection,  raised  by  opponents  of  the  administration  against 
the  methods  outlined  in  the  foregoing  section,  is  the  alleged  danger  of  chang- 
ing a  democracy  into  a  bureaucracy.  Whatever  the  danger,  in  fact,  it  is 
important  to  the  people  and  to  the  scheme  itself  that  the  administration  of 
such  a  law  shall  be  wholly  consistent  with  the  spirit  of  our  institutions  and 
form  of  government.  To  put  it  plainly,  we  believe  in  this  country  that  the 
people  govern  and  are  capable  of  governing.  The  commission  then  must 
be  justified  on  the  ground  that  it  is  an  agency  of  the  people  to  do  for  the 
people  collectively  those  things  which  it  may  do  for  them  better  than 
the  people  could  do  individually  for  themselves.  Being  a  direct  agency  of 
the  people,  the  commission  should  get  close  and  keep  close  to  the  masses  in 
order  that  it  may  correctly  interpret  the  aspirations  and  ideas  of  the  masses 
into  progress  and  human  welfare.  The  commission  cannot  move  much  in 
advance  of  public  sentiment.  Obnoxious  rules  generally  cannot  be  enforced 
even  though  they  are  theoretically  correct.  In  matters  deahng  so  intimately 
with  the  individual  and  the  family  relations  as  the  laws  governing  safety 
and  health,  education  is  a  prime  factor.  And  in  the  administration  of  the 
law  the  rule  of  safety  applies:  "Better  safe  than  sorry."  For  this  reason 
the  law  should  provide,  as  the  Wisconsin  law  does,  for  general  publicity,  and 
the  commission  should  court  the  fullest  publicity  and  cooperation.     The 


Syo  LEGISLATION   AND    GOVERNMENT    STUDY 

term  "reasonable"  in  the  law  may  well  be  held  to  mean  "practicable." 
The  commission  will  not  go  far  if  it  does  not  consider  what  is  practicable, 
and  what  the  people  consider  practicable  may  have  quite  as  much  bearing 
on  the  success  of  the  law  as  what  the  commission  may  deem  practical. 

It  was  upon  consideration  of  these  things,  and  upon  the  further  considera- 
tion that  the  men  actively  engaged  in  production  can  give  most  valuable 
advice,  that  the  Wisconsin  commission  sought  the  cooperation  of  all  inter- 
ested persons  in  forming  an  advisory  committee  in  working  out  standards  of 
safety  and  health.  In  selecting  this  committee  it  was  natural,  of  course, 
that  the  most  progressive  employers  and  employees  should  find  a  place. 
Employers  made  their  own  selection  of  representatives  as  did  the  laboring 
men.  The  membership  of  the  committee  was  completed  by  representatives 
of  the  commission. 

It  has  been  an  inspiration  to  the  commission  to  follow  the  arduous  work 
of  the  committee  day  by  day  and  month  by  month.  Nothing  of  discord, 
nothing  but  sincere,  earnest  effort  to  secure  the  highest  practical  standards 
has  been  evidenced  on  the  part  of  either  employee  or  employer.  Sub- 
committees to  deal  with  technical  subjects  have  given  equally  valuable  serv- 
ice. As  fast  as  facts  have  developed  definite  conclusions,  orders  have  been 
issued.  Orders  have  been  issued  on  the  following  subjects:  elevators,  emery 
wheels,  machines,  fire  escapes,  ventilation,  light,  laundries,  electric  construc- 
tion, building  construction,  dust  extractors,  blowers  and  exhausts  for  fumes 
and  gases,  and  many  other  things.  Progress  is  being  made  all  the  time. 
As  fast  as  accidents  are  reported,  they  are  studied  for  the  remedy.  If  bad 
work  conditions  develop,  every  avenue  of  information  is  sought  to  find  relief. 
Employer  and  employee  in  this  respect  at  least  are  in  full  accord.  I  speak 
in  general  terms;  there  may  be  exceptions  (to  prove  the  rule). 

Here  it  is  well  to  mention  one  essential  difference  between  the  adminis- 
trative orders  of  the  commission  and  former  legislative  enactment.  The 
legislature  must  necessarily  speak  in  comprehensive  terms  and  use  the  phrase- 
ology of  the  law.  The  language  of  such  statutes  often  is  meaningless  to  the 
business  man.  He  may  consult  a  law>^er,  of  course,  but  the  law}'er  may  be 
as  ignorant  of  the  application  of  the  legal  rule  as  the  business  man  is  of  the 
law.  The  commission's  orders,  on  the  contrary,  are  in  the  language  of  trade 
or  business.  They  deal  with  specific  things;  they  are  illustrated  when  neces- 
sary with  pictures  or  blue  prints;  in  short,  they  are  understandable  by  the 
man  on  the  job.  These  orders  are  not  confined  to  the  statutes  in  the  lawyer's 
office;  they  are  published  in  pamphlets  and  mailed  directly  to  the  man  inter- 
ested. If  the  employer  needs  further  information,  the  trained  deputies 
meet  him  on  the  job  for  that  purpose.  Under  the  commission  scheme,  if 
an  order  as  applied  to  a  particular  condition  is  found  impracticable  or  un- 
reas(mable,  the  person  affected  may  petition  the  commission  for  a  hearing 
to  be  relieved  from  the  effect  of  the  order.  This  elasticity  is  a  very  valuable 
feature  of  the  new  idea  over  the  old.     Under  the  old  idea  mistakes  could  not 


EFFECTIVE    LEGISLATION    AND    ADMINISTRATION  87 1 

be  remedied  until  the  legislature  convened  and  many  times  employers  were 
compelled  to  do  useless  things  at  large  expense.  It  necessarily  followed  from 
the  composition  of  the  legislature  and  the  time  it  had  to  devote  to  a  technical 
subject  that  many  mistakes  were  made;  many  laws  were  enacted  which  were 
of  doubtful  benefit  to  the  workmen.  Under  the  new  method,  all  parties 
should  be  benefited.  Changes  will  be  made  gradually.  Factory  conditions 
will  improve  all  the  time  and  production  will  not  cost  more  but  will  cost  less. 
The  relations  of  employers  and  employees  are  improved.  Safeguards  do  not 
come  after  legislative  lobbying  which  is  distasteful  to  both  sides  and  fruitful 
of  ill  will  and  future  friction.  The  whole  proposition  is  reduced  to  the  ques- 
tion of  what  is  reasonable  and  practical;  and  when  that  is  determined,  im- 
mediate results  follow,  results  satisfactory  to  all  concerned. 

SECTION  III 

Relation  of  Compensation  to  Safety. — The  doctors  tell  us  that  for  every 
violation  of  the  laws  of  health,  nature  imposes  a  penalty.  And  we  know 
that  this  is  true.  From  the  "cradle  to  the  grave,"  nature  is  teaching  us 
safety.  Does  the  toddler  fall?  Nature  tells  him  to  be  careful.  Does  the 
boy  too  soon  connect  with  the  green  apple,  or  with  the  cucumber?  Nature 
shouts  its  warning  through  the  stomach.  The  barefoot  boy  with  the  turned 
up  pantaloons  leaves  oflf  his  merry  whistled  tunes  when  he  stubs  his  toe. 
Nature  sounds  its  warning.  Truly  has  it  been  said  that  "Nature  is  a  wise 
old  teacher." 

As  the  young  man  goes  out  into  the  workshop  to  earn  his  right  to  live 
by  brawn  and  brain,  he  carries  with  him  the  experience  of  his  childhood  and 
youth.  That  experience  tells  him  to  have  a  care,  lest  he  experience  physical 
pain  and  suffering.  And  day  by  day  he  gains  in  experience.  He  sees  his 
fellow- workers  fall  by  the  wayside.  He  is  a  witness  to  their  suffering,  anguish 
of  mind  and  body.  He  learns,  too,  how  great  is  the  loss  to  the  family  when 
the  breadwinner  of  the  family  is  stricken.     Nature  teaches  him  to  be  careful. 

The  news  of  the  day  shouts  a  thousand  warnings  to  "be  careful."  But 
business,  industry,  cries  "Hurry!  Hurry!  Hurry! — always  Hurry!"  The 
workman,  the  soldier  of  industry,  is  surrounded  by  a  thousand  dangers.  The 
forces  of  nature,  linked  with  wonderful  machines  devised  by  man,  rise  before 
his  untrained  intellect,  in  bewildering  complexity.  His  sensitive  nerves  be- 
come callous.  Too  often  he  neglects  the  caution  of  experience  and  judgment, 
with  the  result  that  he  is  the  victim  of  accident.  When  he  is  injured,  he 
alone  suffers  the  consequent  physical  and  mental  pain.  No  one  can  share 
these  with  him. 

We  know,  however,  and  we  must  not  allow  our  eyes  to  be  closed  to  the 
fact,  that  neither  the  workman  nor  the  employer  is  alone  to  blame  for  the 
casualties  in  our  industries.  Accidents  result  from  many  contributing  causes. 
The  great  cause,  the  one  overshadowing  all  others,  may  be  called  the  hazard 
of  the  employment. 


872  LEGISLATION    AND    GOVERNMENT    STUDY 

By  Study,  and  by  eternal  vigilance  on  his  part,  the  employer  may  lessen 
the  hazard  of  industry.  The  employee,  likewise,  is  capable  of  reducing  the 
hazard.  But  the  employer  must  not  be  allowed  to  forget  that  he  is  the  cap- 
tain of  the  industry,  and  with  his  rank  goes  the  greater  responsibility.  And  , 
he  must  come  to  a  realization  of  the  fact  that  he  cannot  if  he  would,  shift 
the  burden  from  himself.  The  captain  must  select  for  his  soldiers,  competent 
workmen.  He  must  assign  them  to  the  proper  kind  of  employment,  and 
must  furnish  them  ^ith  safe  places  of  employment.  He  must  surround  his 
workmen  with  fellow-servants  who  are  competent.  He  must  give  to  his 
employees  competent  foremen,  proper  instructions,  and  constant  eflEicient 
supervision.  He  must  inspect  his  machinery,  his  ways,  his  methods,  and 
his  safeguards  at  every  turn.  He  must  not  only  make  reasonable  rules  for 
safety,  but  he  must  enforce  them.  And  when  he  has  done  all  of  these  things, 
he  will  still  have  those  accidents  which  will  come  from  the  hazard  inseparable 
from  industry,  impossible  to  be  foreseen. 

Because  of  the  great  responsibility  imposed  upon  the  employer,  he,  too, 
should  accept  penalty  for  his  failures.  As  the  sensitive  nerves  constantly 
transmit  to  the  brain  of  the  workman  the  warning  to  be  careful,  so  should 
the  sensitive  nerve  of  business  serve  to  warn  the  employer  to  be  careful. 

What  is  the  sensitive  nerve  of  business?  I  need  not  answer  that  question 
for  you.  You  know  that  it  is  the  dividend.  You  may  talk  about  humanity 
until  doomsday.  But  our  feelings  of  compassion  for  the  unfortunate  are 
touched  after  the  accident — not  before.  And  then  we  spend  but  little  time 
in  vain  regret.     We  turn  to  our  business,  and  business  means  dollars. 

Now,  the  workman  is  penalized  in  every  case  of  accident  by  the  suffering 
incident  to  his  injury.  So,  too,  the  sensitive  nerve  of  the  employer,  his 
dividend,  must  be  touched  in  every  case  of  accident  if  he  is  to  be  spurred  to 
his  full  duty.  This  means  that  when  a  workman  suffers  from  accident,  the 
employer  must  suffer  in  the  way  most  certain  to  teach  him  the  care  due  his 
employee.  By  this  method,  and  by  this  method  only,  can  the  employer  be 
made  to  realize  and  appreciate  the  necessity  of  guarding  against  accident — 
be  made  to  respond  to  his  full  duty  in  that  respect.  This  penalty  will  bring 
response. 

Just  for  a  moment  contemplate.  During  the  12  months  from  September 
I,  1911,  to  September  i,  1912,  exclusive  of  accidents  in  the  railroad  service, 
there  were  in  the  state  of  Wisconsin  over  6500  accidents,  each  of  which  caused 
disability  on  the  part  of  the  workman  for  more  than  7  days.  This  would 
seem  to  be  worse  than  war.  At  least  more  men  were  injured  during  that 
time  than  were  wounded  during  the  same  time  in  the  Spanish-American  or 
the  Philippine  wars.  And  mind  you,  50  per  cent,  of  the  time  loss  incident 
to  these  casualties  could  have  been  saved  by  the  employers  had  their  full 
duty  been  done  as  here  outlined. 

Here  then  we  have  the  relation  between  accident  prevention  and  work- 
men's compensation.     They  are  obviously  correlated.     One  is  the  comple- 


EFFECTIVE    LEGISLATION   AND    ADMINISTRATION  873 

ment  of  the  other,  and  they  should  both  be  administered  by  the  same  body 
so  that  the  relation  of  prevention  and  compensation  may  always  be  kept 
before  the  employer.  It  is  for  this  reason  that  self  insurance  is  best  for  safety, 
and  next  to  self  insurance  comes  mutual  insurance.  All  insurance  should 
carry  credit  for  good  work  on  the  part  of  the  employer  for  accident  preven- 
tion, and  countercharges  for  poor  work.  Let  this  be  a  contest  in  which  money 
is  to  be  saved;  then  watch  results. 

All  the  time  the  employer  should  be  made  to  feel  the  relation  of  accidents 
to  the  cost  of  compensation.  And  it  is  workmen's  compensation  that  brings 
this  home  to  the  employer  as  nothing  else  will. 

We  are  pleased,  indeed,  that  progressive  employers  everywhere  are  taking 
into  account  the  maimed  and  dead  workmen.  They  are  beginning  to  count 
the  cost  of  personal  injury  in  dollars.  This  presages  saving  of  life  and  limb — 
preserving  to  the  family  the  breadwinner — preventing  suffering  and  want. 

In  Wisconsin  the  factory  inspector  used  to  compel  safety  with  a  big  stick. 
He  was  the  policeman  with  the  club.  Now,  the  function  of  the  commission 
is  to  point  the  way  to  safety — the  employer  will  do  the  rest. 

Since  the  workmen's  compensation  acts  of  the  past  2  years,  more  real 
safety  work  has  been  done  in  the  United  States  than  in  any  10  years  preced- 
ing. This  is  due  almost  wholly  to  a  fuller  realization  of  the  cost  of  accidents 
on  the  part  of  the  employers.  As  the  relative  cost  of  accident  becomes 
greater,  the  necessity  for  accident  prevention  becomes  the  more  apparent. 

No  statute  ever  has  been  or  ever  can  be  enacted  that  will  efficiently  safe- 
guard the  worker  except  one  that  automatically  provides  the  penalty  for  the 
employer  for  each  and  every  injury  received  in  the  work  places  as  the  result 
of  accident.  The  compensation  act  provides  the  penalty  and  at  the  same 
time  subserves  society  as  a  whole  by  distributing  the  burden  of  loss  from  the 
weaker  members  of  society  to  society  as  a  whole.  But  of  more  importance 
than  the  relief  to  the  injured  worker,  which  comes  from  compensation,  is  the 
prevention  of  injury  because  of  compensation.  Heretofore  the  efficiency 
expert  has  studied  his  subject  almost  wholly  from  the  standpoint  of  increased 
production  to  reduce  the  unit  of  cost.  Let  us  not  forget  that  the  thing  pro- 
duced is  only  valuable  as  it  conduces  to  the  welfare  of  man.  No  increase  of 
production  is  desirable  that  adds  to  the  sum  total  of  human  misery.  He  is 
no  benefactor  of  mankind  who  makes  two  blades  of  grass  grow  where  one 
grew  before,  if  in  so  doing  he  sacrifices  human  happiness. 

SECTION  IV 

The  Practical  Equipment  of  the  Place  of  Employment  to  Prevent  Accident 
and  Disease.- — There  is  no  definite  guide  for  safety  of  life  and  health  for  the 
employer  and  employee.  The  careful,  intelligent  guarding  of  machines, 
ways  and  works,  will  work  wonders.  Proper  lighting  will  greatly  lessen 
accidents,  safeguard  the  eyes,  increase  the  output,  increase  the  efficiency  of 


874  LEGISLATION   AND    GOVERNMENT    STUDY 

the  employee,  and  contribute  greatly  to  good  cheer  in  the  institution.  Prop- 
erly constructed  exhausts  will  remove  dusts,  gases,  and  impure  air.  Good 
ventilation  wUl  do  much  to  keep  the  workmen  fit  for  work.  In  short,  me- 
chanical devices  will  obviate  many  of  the  dangers  to  which  the  workmen 
are  ordinarily  exposed.  The  progressive  employer  in  6  months'  time  at  a 
very  reasonable  outlay  can  make  his  plant  up-to-date  in  these  respects. 

When  he  has  done  all  these  things,  he  has  fallen  far  short  of  possible 
results  in  protecting  workmen  from  injury  and  disease.  Take  a  poor  shop 
and  equip  it  perfectly  with  all  modern  safeguards  and  you  have  made  only 
about  one-third  the  possible  saving  in  accidents  and  disease.  The  other 
two-thirds  must  come  from  cooperation  on  the  part  of  the  workmen  them- 
selves. Education  of  the  worker  to  exercise  the  highest  degree  of  care  is 
necessary.  This  can  be  done.  It  has  been  done.  It  is  being  done  every 
day.  Shop  organization  and  discipline  in  the  factory  or  workshop  is  just  as 
much  the  duty  of  the  employer  as  to  build  mechanical  safeguards.  The 
employer  is  the  responsible  party.  He  can  secure  cooperation  of  his  workers, 
if  he  will.  If  he  will  take  his  men  into  his  confidence,  they  will  respond.  If 
he  will  organize  safety  committees  among  the  men  and  give  them  responsi- 
bility and  intelligent  supervision,  he  will  get  immediate  returns.  Accidents 
will  decrease  wonderfully  and  immediately.  Better  shop  conditions  will 
come  about.  He  will  see  increased  production  and  a  healthier  shop  and 
crew.  It  will  pay.  More  and  better  work  will  be  done.  It  will  not  cost 
as  much  in  damages  for  compensation.  There  will  not  be  so  much  time  lost. 
There  will  not  be  so  much  shifting  of  men  with  the  consequent  loss  in  break- 
ing in  new  men. 

It  is  not  enough  to  make  assertions.  They  may  seem  extravagant.  But 
we  have  facts  to  prove  these  assertions.  The  new  method  in  Wisconsin 
began  in  September,  191 1,  but  was  not  fairly  in  operation  until  a  year  later. 
Here  are  some  records,  just  a  few  out  of  the  many,  which  we  have  of  things 
done  and  being  done.  I  compare  2  months— July  and  August,  191 2 — with 
the  same  months  19 13,  to  show  accident  reductions: 

Savings  Achieved  by  a  Few  Manufacturers  Covering  Two  Separate  Accident 

Periods 

Accidents  in  1  J^V  ^^^   |  J^y  ^^^   \  Decrease. 

Aug.,    i9i2!Aug.,    1913    per  cent. 

Simmons  Manufacturing  Co.,  Kenosha 269  {       146  45.6 

Pfister&Vogel Leather  Co.,  Milwaukee 371  !       106  !     71.4 

Nordberg  Manufacturing  Co.,  Milwaukee :....' 177  63  64.4 

Bucyrus  Co.,  South  Milwaukee 379  172  54. 7 

Chain  Belt  Co.,  Milwaukee 121  58  52.1 

National  Brake  &  Electric  Co.,  Milwaukee 127  '         29  77.  i 

A  Still  more  favorable  showing  may  be  made  if  we  compare  the  nature  of 
the  accidents.     The  time  lost  per  accident  shows  up  equally  well.     These 


EFFECTIVE    LEGISLATION    A>JD    ADMINISTRATION  875 

figures  demonstrate  conclusively  the  possibilities  in  this  country.  We  have 
been  killing  and  maiming  our  workers  by  the  hundreds  of  thousands  each  year. 
Not  even  the  civil  war  compares  in  disastrous  results  in  killed  and  wounded 
with  the  peace  of  industry.  Industry  claims  its  awful  toll  day  by  day  until 
a  nation  is  hardened  to  think  that  such  is  the  price  of  industrial  prosperity. 
The  unnecessary  killing  of  a  human  being  is  manslaughter,  and  the  penalty 
for  manslaughter  is  a  term  in  the  penitentiary.  Our  state  prisons  would  be 
full  to  overflowing  if  the  criminal  law  had  been  strictly  enforced.  And  still 
you  cannot  indict  a  whole  people.  A  people's  conscience  is  asleep,  but  it  is 
being  aroused.  The  criminal  law  is  not  the  answer.  But  the  burden  to 
care  for  the  injured  and  their  dependents  is  going  to  be  charged  to  the  indus- 
try. The  employer  who  can  save  here  will  win  in  the  competitive  field. 
He  can  win  now,  and  he  had  best  put  his  house  in  order. 

There  are  some  fundamental  things  to  do;  among  others  I  refer  to  the 
first  rules  of  safety  adopted  by  the  industrial  commission.  These  rules  are 
being  added  to,  as  a  study  of  conditions  demand  action.  Some  of  the  com- 
mission's orders  are  as  follows: 

Order  2. — Pullej^s — guards.  All  puUeys  over  18  in.  in  diameter,  which  are  exposed  to 
contact,  must  be  guarded. 

Order  3. — ^Loose  pulleys.  All  machines,  not  individually  motor  driven,  must  be 
equipped  with  a  loose  pulley  or  a  clutch  or  some  other  adequate  means  of  stopping  the 
machine  quickly. 

Order  4. — Belt-shifters.  All  loose  pulleys  must  be  furnished  with  a  permanent  belt- 
shifter,  so  located  as  to  be  within  easy  reach  of  the  operator.  The  belt-shifter  must  be  so 
constructed  as  to  make  it  possible  for  the  belt  to  creep  from  the  loose  pulley  back  on  the 
tight  pulley. 

All  belt-shifters  must  be  equipped  with  a  lock  or  some  other  efficient  device  which  will 
prevent  the  shifter  from  being  accidentally  shifted. 

Order  5. — Pulleys  near  shaft  hanger.  Pulleys  must  be  so  placed  as  to  allow  the  width 
of  the  belt  between  two  pulleys,  or  between  the  pulley  and  the  shaft  hanger,  or  a  hook  must 
be  provided,  or  a  guard  placed  adjacent  to  the  pulley  to  prevent  the  belt  from  leaving  the 
pulley. 

Order  11. — Gears.  All  gears,  where  exposed  to  contact,  must  be  entirely  enclosed  or 
equipped  with  a  flange  guard  which  must  enclose  the  teeth  of  the  gears.  All  arm  or  spoke 
gears  and  all  web  gears  with  holes  in  the  web,  which  are  over  18  in.  in  diameter,  where 
exposed  to  contact,  must  be  entirely  enclosed. 

Order  12. — Keys  and  keyseats.  All  projecting  keys  in  shafting,  where  exposed  to  con- 
tact, must  be  cut  off  or  guarded,  and  all  keyseats  in  end  of  shafts,  where  exposed  to  contact, 
must  be  filled  or  guarded. 

Order  9. — Flywheels.  All  sections  of  flywheels,  with  spokes,  which  are  6  ft.  or  less 
from  the  floor  and  which  are  exposed  to  contact,  must  be  guarded. 

These  orders  are  included  here  only  to  give  an  idea  of  their  practicability 
and  to  demonstrate  that  the  commission's  safety  rules  are  expressed  in 
language  that  is  familiar  to  shop  foremen  and  superintendents.  At  the 
present  time  the  commission's  safety  orders  include  rules  relating  to  pubHc 
buildings,  building  construction,  machinery  safeguards,  sanitation,  passenger 
and  freight  elevators  and  electrical  equipment. 


INDEX  OF  AUTHORS 


A 


Abrahamson,  A.,  on  carbon  monoxide 
psychoses,  64 

Adams,  S.  S.,  on  nitro-benzol  poisoning,  544 

Admiralty  Committee  (British),  on 
"bends."  201 

Admiralty  Committee  (British),  on 
ordinary  time  limits  of  divers,  for 
caisson  and  tunnel  work,  203 

Agasse-Lafont,  on  benzol  or  benzene,  140 

Agriculture,  U.  S.  Dept.  of,  Report  in  1904 
on  arsenic  in  wall  papers,  3,  4 

Ahrens,  on  dust,  438,  595 

Air-workers'  union,  stipulations  for  caisson 
work,  202 

Aitkin,  Dr.  Francis,  on  the  curability  of 
silicosis,  234 

Aitoff,  v.,  35 

Alberti,  on  gangrene  following  gassing,  66 

Albrecht,  ix,  11 

Allbutt,  on  occupation  neuroses,  270 

AUen,  on  skin  affections,  371 

Althaus,  272,  274 

American  Association  for  Labor  Legislation, 
Study  of  industrial  phosphorus  poison- 
ing by, 156 

American  Museum  of  Safety,  xiii 

Anaker,  on  glass  polishers,  639 

Andrews,  Irene  O.,  protection  of  health  of 
women  wage  earners,  831 

Andrews,  on  anthrax  in  man,  169,  172 

Andrews,  on     fragilitas  ossium,"  151 

Andrews,  Dr.  John  B.,  xiii 

Andrews,  John  B.,  on  60  cases  of  industrial 
plumbism  in  New  York  State,  103 

Andrews,  on  the  destructiveness  of  phos- 
phorus poisoning,  148 

Andrews,    John  B.,  on  lead  poisoning,  15, 

Andrews,  J.  B.,  on  methods  and  scope  of 
legislation,  802 

Andrews,  John  B.,  on  phosphorus  poison- 
ing, 14 


Andrews,  Dr.  John  B.,  on  phosphorus 
poisoning  in  the  match  industry  in  the 
United  States,  xii 

Andrews,  John  B.,  on  the  prevention  of 
phosphorus  poisoning,  153-157 

Andry,  on  skin  affections  of  milk  men,'374 

Apfelbach,  G.  L.,  M.  D.,  43-74 

Apfelbach,  George,  on  electrical  ophthal- 
mia, 588 

Apfelbach,  G.  L.,  on  electric  ophthalmia, 
412 

Arlidge,  Lx.  11 

Armit,  19 

Armit,  H.  \V.,  on  nickel  carbonyl,  584 

Arustein,  18 

Ascher,  on  brick  and  stone  masons,  634 

Ascher,  on  chlorine  and  iodine,  539 

Ascher,  on  mine  dust,  621 

Austrian  factory  inspectors  reports,  de- 
scription of  fatal  cases  of  benzol  poison- 
ing in,  141,  142 

Austrian  government,  committee  of  in- 
quiry of  industrial  phosphorus  poisoning, 

155 
AjTes,  on  fatigue,  253 


B 


Baly,  81 

Bard,  cases  of  homicide  and  suicide  from 

carbon  bisulphide  reported  by,  41 
Barr,   on  normal  hearing  of  boiler  makers, 

345 

Baskerville,  C,  on  air  impurities:  dusts, 
fumes  and  gases,  778 

Bassett,  17,23 

Bassoe,  on  permanent  injury  due  to  com- 
pressed-air illness,  199,  200 

Bates,  Mrs.  Lindon  W.,  xiii 

Bates,  Mrs.,  L.  W.  on  felt  hat  workers,  531 

Bauer,  on  alum  ulcers,  575 

Bauer,  on  chemical  workers,  420 

Bazin,  on  liability  to  a  cutaneous  disturb- 
ance   of    men    employed    in    quinine 


877 


878 


INDEX    OF    AUTHORS 


factories    in    France,    Germany    and 

England,  369 
Beard,  274 

Beard,  on  writers'  cramp,  275 
Beatty,    G.,  on  boot  and  shoe  makers,  659 
Beers,     on    cause    of    dermatitis    among 

photographers,  362 
Bell,  Charles,  270 
Benedikt,    on   occupation    neuroses,    270, 

272,  273,  274,  277 
Bennett,    H.  G.,  on  ''the  Manufacture  of 

Leather,"  300 
Berbes,  39 

Berger,  272,  274,  276 
Bernhardt,  .272,  274 

Bernhardt,  on  causes  of  writers'  cramp,  281 
Bernhardt,  on  coxa  vara  in  agriculturists,  670 
Bert,  on  compressed-air  illness,  191,  196 
Bert,  on  mortality  in  cases  of  compressed- 
air  illness,  200 
Berthenson,      on     constant     inhaling     of 

benzine   fumes,    139 
Berthenson,  Leo,  on  diseases  of  petroleum 

workers,  548 
Bertrand  et  Javillier,  18 
Besiner,  on  glanders,  372 
Beth,  on  dust  filters,  441 
Bianchi,    C,   histopathological    researches 

in  overexertion,  770 
Bing,  272,  273 
Binswanger,  272,  274 
Biondi,  as  to  cases  of  lead  poisoning  among 

lead  miners  in  Sardinia,  113 
Blake,  Clarence  John,  on  occupational  in- 
juries and  diseases  of  the  ear,  339-350 
Blaschko,     on    an    affection    common    in 

workers  in  silver,  353 
Blaschko,  on  dermatitis  in  aniline  workers, 

363 
Blaschko,    on  skin  affections  in  furniture 

polishers,  360 
Blegvad,     on    impairment    of    hearing    of 

telephone  operators,  349-350 
Bleile,  A.  M.,  on  cause  of  death  in  electric 

shock,  408 
Blum,   on    animal   experimentation   as   to 

insolubility  of  lead  sulphide,  113 
Bogardus,  on  fatigue  and  accidents,  265 
Bolam,  R.  A.,  on  cause  of  death  in  electric 

shock,  407 
Bonnier,  271 
Bonnus,  272 
Bornstein,  in  re  "stage  decompression,"  204 


Bowen,  John  T.  on  occupational  affections 

of  the  skin,  351-379 
Bownot,    on  theories  of  death  in  electric 

shock,  403 
Boycott,     on   compressed-air   illness,    188, 

191,  192 
Boycott,    on  method  of  decompression  to 

minimize    dangers    of    compressed-air 

work,  204-206 
Boyle,  on  caisson  disease,  188 
Brand,  on  the  discovery  of  white  or  yellow 

phosphorus  in  1669,  153 
Brezina,  on  absorption  of  lead  sulphide  by 

the  body,  113 
Briau    (de   Crensot),   on  mental  effect    of 

repairers   of   belts   using   cement   dis- 
solved in  carbon  bisulphide,  36,  39,  41 
Brissaud,  272,  274 
Brissaud,  Hallian  and  Meige,  282 
British  Admiralty  Committee  on  Deep  Sea 

Diving,   adoption  of   "stage"   method 

of  decompression  by,  204,  205 
British  Admiralty  Committee  on  Deep  Sea 

Diving,  report  on  decompressions,  189 
British  Association,  Committee  of  the,  on 

fatigue,  257,  266 
British  Factory  Inspectors,  laws  on  carbon 

monoxide  poisoning  enforced  by,  67,  68 
British   Report,  on  phosphorus  poisoning, 

145 
British  Report  to  the  House  of  Lords,  on 

phosphorus  poisoning,  149 
Brocoorens,  on  "fragilitas  ossium,"  151 
Brooklyn  Bridge,  cf.  compressed-air  illness, 

188 
Brown  (Winslow  and  Brown),  microbes  in 

air,  779 
Brown,  on  "The  theatrical  profession  as  a 

factor  in  the  dissemination  of  disease," 

374 
Brown,  H.  H.,  on  grain  dust  explosions,  686 
Brown,    Dr.    Sanger,    on     dementia    with 

amnesia  following  "gassing,"  64 
Briick,  270 
Bryant,  L.  T.,  on  sanitary  standards  in  the 

felt  hat  industry,  532 
Burry,   Dr.   James,   on    carbon   monoxide 

psychoses,  64 
Burton,  cf.  Burtonian  line,  85 
Butler,  on  nystagmus,  624 
Butler  and  Huber,  on  deaths  from  anthrax 

through  infected  meat,  170 
Buttersach,  19 


INDEX    OF   AUTHORS 


879 


Canstatt,  on  occupation  neuroses,  270 
Carlson,  Dr.  A.  J.,  on  the  poisoning  from 

galena  ore,  113 
Carozzi,  Dr.,  Chief  of  Investigating  Dept., 

Milan  Clinic,  Researches,  774 
Caryophilis,  on  sulphur  miners,  623 
Casamajor,  17 
Casamajor,  Louis,  on  manganese  poisoning, 

I 19-125 
Cash,  on  epidemics  of  dermatitis  from  satin 

wood, 365 
Cassirer,  272,  274 

Cazaneuve,  on  poisonous  dyes,  655 
Cenci,  Francesco,  obtained   blood  findings 

in  workers  afflicted  with  carbon  bisul- 
phide poisoning,  38 
Chassevent,  on  benzol  or  benzene,  140 
Church,  272,  274 
Chyzer,  on  pottery  workers,  634 
Clague-Oliver,  on  preventive  and  curative 

method  of  treatment  for  chronic  lead 

poisoning,  93,  94 
Clark,  H.  W.,  on  air  in  textile  mills,  651 
Claude,  on  benzol  poisoning,  142 
Cochrane,  on  the  caisson,  187 
Cohn,  272,  274 
Cohnheim,  on  cancer,  381 
CoUis,  on  dusts  of  vegetable  tissue-,  297 
Collis,  on  effect  of  dust  on  granite  cutters, 

297 
Collis,  on  exanthema  produced  by  mercury 

in  industrial  establishments,  131 
Collis,   on    prevention  of  development  of 

ulcers,  305 
Commerce  and  Labor,  Department  of,  in- 
vestigation of  conditions  of  labor  in 

iron  and  steel  factories,  262 
Committee   of  the  British  Association,  see 

British 
Conference,  on  occupational  diseases,  15 
Corbin,  on  smallpox,  425 
Coronulas  (Athens,  Gr.),  36 
Cottrell,  on  cement  works,  441 
Craig,  on  malarial  parasites,  174 
Cridland,  on  ray  cataract,  638 
Crocker,  on  a  cause  of  dermatitis,  361 
Crocker,  on  dermatitis  in  flute  makers,  365 
Crone,  on   reports  of  poisoning  from  arse- 

niureted  hydrogen  gas,  213 
Crooks,  William,  on  debate — whether  heat 

or  light  rays  caused  cataract — physical 

side,  336 


Crownhart,  C.  H.,  effective  legislation  and 
administration,  867 

Cruice,  J.  M.  and  Jump,  H.  D.,  38,  39 

Curschmann,  273 

Curshman,  273 

Curschmann,  on  diseases  of  chemical  work- 
ers, 535,  536,  544 

Czaplewski,  on  nitrous  fumes,  538 


D 


Da  Costa,  on  soldiers'  irritable  heart,  705 
Da  Costa,  on  tobacco  heart,  482 
Daifis,  on  wood  alcohol,  676 
Damant,  on  caisson  disease,  188 
Damant,  on  compressed-air  illness,  192 
Damant,  on    method  of  decompression  to 

minimize    dangers    of    compressed-air 

work,  204 
Dammer,  ix,  11 
Daniels,  Dr.  Anna  S.,  on  tenement  factories, 

453 
D'Arsonval,  on  theories  of  death  in  electric 

shock,  403 
Davaine,  on  bacillus  anthracis,  158 
Davy,  Sir  Humphrey,  experiments  on    tox- 
icity of  carbon  monoxide,  45 
Day,  Dr.  W.  L.,  on  stone  polishing,  626 
Dean,  H.  M.,  on   soldiers'  irritable  heart, 

70s 
Dearden,  on  poisonous  dyes,  656 
Delavan,  on  automobilists,  716 
Delpech,  on  asthma,  303 
Delpech,  gave  first  comprehensive  picture 

of   symptomatology   of   bisulphide    of 

carbon  poisoning,  35,  39,  41 
Demetjeff,  on  lifting  power,  449 
Derville  and  Guermonprez,  on  papillomata 

in  workers  in  petroleum  refineries,  367 
De  Schweinitz,  on  puddlers'  cataract,  588 
De  Schweinitz,  on  tobacco  amblyopia,5698 
Destarac,  272 
Determann,  273 
Deuchenne    de    Boulogne,    on    paralyzing 

effects  of  carbon  bisulphide,  35 
Devoto,  Prof.  L.,  x 
Devoto,  L.,  12,  418 
Devoto,  L.,  on  Milan  Clinic,  765-776 
Ditman,  Dr.  N.  E.,  13,  xiii 
Dodd,    on     treatment    of    acute    Rontgen 

dermatitis,  396 
Doehring,  Dr.  C.  F.  W.,  xii 
Doehring,  C.  F.  W.,  on  factory  sanitation, 

14 


88o 


INDEX    OF    AUTHORS 


Doehring,  C.  F.  W.,  on  oil  cloth,  551 
Doehring,  C.  F.  W.,  on  tallow,  680 
Donlin,  Icllinck,  on    theories  of  death  in 

electric  shock,  403 
Duchenne,  on  occupation  neuroses,  270 
Duchenne,  273 

Duchenne,  on  occupation  neuroses,  274 
Dufour,   on    intoxication   from  inhalation 

of  fumes  of  benzine,  137 
Dumas,  on  water-prooved  clothing,  464 
Dutton,  W.  F.,  on  vanadium  poisoning,  606 


Ebright,  Geo.  E.,  on  miners,  621 

Ebright,  Geo.  E.,  on  nitro-glycerine,  560 

Edinger,  on  stonecutters'  disease,  290 

Edsall,  Dr.  D.  L.,  xiii 

Edsall,  D.  L.,  on  mercurial  poisoning  in 
dentists  and  physicists,  525 

Edsall,  on  personal  experience  among  zinc 
workers,  121 

Edsall,  D.  L.,  on  sciatica  in  locomotive 
engineers,  712 

Edsall,  on  toxaemia,  396 

Ehrlich,  maintains  that  basophilia  is 
diagnostic  of  plumbism,  83 

Ehrmann,  on  mercury  exanthema,  130 

Elliot,  on  "pseudo-pigmentation  on  the 
hands  of  millers,"  353 

Ellman,  on  variation  of  symptoms  of  lead 
poisoning,  126 

Emden,  see  manganese,  119,  120,  etc. 

Epstein,  on  diseases  of  tailors,  661 

Erb,  273 

Erdman,  Seward,  on  compressed-air  ill- 
ness, 187-210 

Erskine,  Miss  Lilian,  on  exposure  to  phos- 
phorus fumes  in  the  making  of  fire- 
works, 14s,  146 

Engling,  on  absorption  of  lead  sulphide  by 
the  body,  113 

Eulenberg,  ix,  11,  63 

Evans,  C.  S.,  on  nitro-glycerine,  559 

Eysel,  on  syphilis  in  glass  blowers,  638 


Farmer,  Moore  and  Walker,  on  cancer,  381 
Fawoeski,  130 

Fay,  Albert  H.,  on  accidents  in  mines,  619 
Felix,  on    experimentation  with  different 
benzines,  137 


Fere,  271 

Fessenden,  S.  D.,  xi 

Fessenden,  S.  D.,  13 

First  National  Conference  on  Occupational 

Diseases,  xiii 
Fischbein,  62 
Fischer,  on  ointment  causing  disappearance 

of  ulceration  on  the  septum,  305 
Fischer,  Irving,  on  exercise,  447 
Fischer,  R.,  on  industrial  poisons,  418,  422 
Fischer   and  Lehmann,   on    conditions  in 

bichromate  works  in  Germany,  305 
Fischer  and  Sommerfeld,  38 
Fisher,  on  fatigue,  255 
Fiske,  C.  N.,  719 
Fiske,    C.    N.,    surgeon,    on    occupational 

disability  in  the  U.  S.  Navy,  719 
Fiske,   C.  N.   (surgeon    U.    S.    Navy),  on 

occupational   distribution   of   physical 

disability  in  the  U.  S.  Navy,  719 
Fleck,  A.,  on  diseases  of  painters,  516 
Flemming,  on   the  dangers  of  tight-fitting 

clothing  in  aviation,  216 
Fleury,  on  death  in  electric  shock,  407 
Fordyce,  on  dermatitis  in  sugar  refineries, 

358 
Fordyce,  on   occupational  dermatoses,  354 
Foske,  Dr.   C.  LeNeve,  on    the  sensations 

and  symptoms  experienced  upon  being 

"gassed"  in  mine  air,  59,  60 
Frankl-Hochwart,  271,  272,  273,  274 
Frankl-Hochwart  (von),  on  tetany,  657 
Freund,  E.,  on  police  power,  857 
Friedenwahl,  H.,  39 

Friedrich  and  Jaehne,  on  clinical  observa- 
tions of  effect  on  ear  of  intense  sounds 

of  high  pitch,  348 
Fromm,  on  dust  in  printing  establishments, 

610 
Frothingham,Langdon,  on  anthrax, 158-172 


Gaillot,  on  cause  of  lymphangitis  occurring 
in  workers  in  sugar  refineries,  359 

Galen,  vii 

Galet,  O.,  36,  38,  39 

Galezowski,  on  tobacco  amblyopia,  698 

Ganassini,  17 

Gantt,  on  scientific  management  of  fatigue, 
267 

Gardner,  on  lead  poisoning,  517 

Gardner,  Henry  A.,  81 


INDEX    OF    AUTHORS 


88 1 


Garforth,  on  mine  dust,  621 

Garman,  on  phosphorus  poisoning,  148,  151 

Gamier,  on  benzol  or  benzene,  140 

Gast,  on   diseases  of  hotel  and  restaurant 

employees,  699 
Geist,  on  phosphorus  poisoning,  150 
German  Factory  Inspectors,  Report  of,  on 

benzine  poisoning,  138 
Giegel.  274 
Giese,  G.,  on  carbon  monoxide  psychoses, 

64 
Giesel,  Curie  and  Becquerel,  on   effect  of 

radium  rays,  398 
Gilchrist,  on  erysipeloid,  373 
Glaister,    Professor   John,    monograph    on 

cases  of  poisoning  from   arseniureted 

hydrogen  gas,  8 
Glaister,  on   poisoning  from  arseniuretted 

hydrogen  gas  in  ballooning,  213 
Gilbert,  Dr.,  83 

Gilbert,  on  disease  of  the  nail,  374 
Gilbert,  on  felt  hat  workers,  530 
Gilbert,  on  furriers'  skin  affections,  576 
Gilbert,  on  weakness  of  the  hand,  etc.,  in 

industrial  mercurialism,  130 
Goadby,  88,  89 
Gocht,  on  X-ray,  391 

Goeneu,  on  cases  of  X-ray  carcinomata,  394 
Goldflam,  273 

Goldmark,  Josephine,  14,  16,  268 
Goldschmidt,  on  chronic  benzine  poisoning, 

139 

Goldstein,  273 

Goldwater,  S.  S.,  14 

Gorgas,  W.  C.,  surgeon  general,  on  pneu- 
monia, 431 

Gorgas,  General,  on  prophylaxis  of  malaria, 
176 

Gothlin,  on  the  amount  of  mercury  neces- 
sarj-  to  cause  poisoning,  132,  133 

Gottschalk,  on  diseases  of  clay  workers,  628 

Gottstein  and  Kayser,  on  deafness,  598 

Gottstein  and  Kayser,  on  impairment  of 
hearing  of  smiths  and  machinists,  345 

Gowers,  286 

Gowers,  on  occupation  neuroses,  274,  276, 
278 

Gowers,  case  of  pseudomyasthenia  reported 

by, 138 
Gowers,  on  writers'  cramp,  282 
Grab,  on  limestone  workers,  623 
Gradeingo,    on    causes   of   impairment   of 

hearing,  346 

.     56 


Grandhomme,  on  methyl-iodine  poisoning, 
539 

Grandhomme,  on  nitro-benzol  poisoning, 
544,  546 

Grawitz,  maintains  that  basophilia  is  diag- 
nostic of  plumbism,  83 

Great  Britain,  cases  of  industrial  phos- 
phorus poisoning  reported  to,  previous 
to  1911,  145 

Greenhow  (cited  by  Arlidge),  23 

Greenwood,  on  caisson  disease,  188 

Greenwood,  on  experiments  bearing  upon 
caisson  workers,  202 

Greenwood,  on  lack  of  evidence  of  supe- 
riority of  the  "stage"  method  of 
decompression  over  the  uniform  decom- 
pression, 207 

Greenwood,  in  re  theories  on  compressed- 
air  illness,  190 

Grempke,  on  phosgene  poisoning,  540 

Gruber  and  Robert,  on  toxicity  of  carbon 
monoxide,  45,  47 

Gruenberg,  on  experiments  \rith  sound 
waves,  347 

Griin,  on  diseases  among  soap  makers,  681 

Gudzent  and  Halberstaedter,  on  result  of 
repeated  exposure  to  radioactive  sub- 
stances, 399 

Gundermann,  on  benzol  or  benzene  poison- 
ing, 141 

Gundermann,  on  experimentations  with 
different  benzines,  137 

Gunn,  Selskar  M.,  on  industrial  incidence 
of  tuberculosis  in  Massachusetts,  484 

Gusenbauer,  on  osteomyelitis,  644 

Guttstadt,  on  alcohol  in  relation  to  tuber- 
culosis, 428 


H 


Habermann,  on   impairment  of  hearing  of 

boiler  makers,  345 
Hahn,  M.,  on  diseases  in  printers,  610 
Haldane,   on    compressed-air  illness,    188, 

190,  191,  193,  194 
Haldane,  on  length  of  exposure  at  different 

pressures  in  caisson  and  tunnel  work, 

203 
Haldane,  on  maximum  pressure  for  divers 

on  construction  work,  202 
Haldane,  on    method  of  decompression  to 

minimize    dangers    of    compressed-air 

work,  204-208 


INDEX   or   AUTHORS 


Haldane,  on  mine  air,  620 
Haldane,  on  rate  of  decompression  in  cais- 
son and  tunnel  works  (table),  205,  206 
Haldane,  in  re  theories  on  compressed-air 

illness,  190 
Haldane,  on   toxicity  of  carbon  monoxide, 

45,  46 
Halford,  ix,  11 
Hall,  on  causes  of  an  eruption  of  the  type 

of  a  papular  or  papulo-vesicular  eczema. 

361 
Halley,  diving  bell  devised  by,  187 
Hallian,  274 
Hallion,  272 

Hamer,  on  the  hide  industry,  573 
Hamilton,  Dr.  Alice,  xiii 
Hamilton,  Dr.  Alice,  on  arsenic  workers,  486 
Hamilton,  Dr.  Ahce,  on  chronic  phosphorus 

poisoning,  145-152 
Hamilton,   Dr.   Alice,   on    examination   of 

patients  with  lead  poisoning,  90 
Hamilton,  Dr.  Alice,  on  hygiene  of  painters, 

15 

Hamilton,  Dr.  Alice,  on  industrial  aniline 
poisoning,  570 

Hamilton,  Dr.  Ahce,  on  industrial  phos- 
phorus poisoning,  145,  152 

Hamilton,  Dr.  Alice,  on  lead  poisoning,  15, 
102,  117,  513,  517 

Hamilton,  Dr.  AUce,  on  lead  poisoning  in 
the  United  States,  102-118 

Hamilton,  Dr.  Alice,  on  naphtha  and  ben- 
zol poisoning,  136,  144 

Hamilton,  Dr.  AUce,  on  pottery  workers, 
632 

Hamilton,  Dr.  Alice,  on  tin  plating,  605 

Hanke,  on  nitro-naphthalene,  546 

Hanna  and  Hope,  on  anthrax  in  man  in 
Liverpool,  169 

Hanson,  W.  C,  on  cotton  industry,  647 

Hanson,  W.  C,  on  dangers  from  dust  and 
fumes,  14 

Hanson,  Dr.  William  C,  on  dusty  trades 
in  Massachusetts,  xii 

Hanson,  W.  C,  on  exhibits  relating  to 
occupational  diseases,  14 

Hanson,  W.  C,  lack  of  authority  to  exclude 
young  workers  physically  unfit,  849 

Hanson,  Metal,  and  Chem.  Eng.,  16 

Hanson,  Dr.  William  C,  photographs  illus- 
trating dangers  to  workers,  etc.,  xiii 

Hanson,  W.  C,  state  inspectors  and  phy- 
sicians, 861 


Harrington,  on  cause  of  poison  of  cap  maker, 

362 
Harris,  J.  R.,  Dr.,  U.  S.  A.,  on  flat  feet,  445 
Haskovec,  274 
Hauft,  Hans  George,  37 
Hayhurst,  E.  R.,  xiii 
Hayhurst,  E.  R.,  on  brass,  copper  and  zinc 

poisoning,  15-26 
Hayhurst,  E.  R.,  on  brass,  copper  and  zinc 

workers,  491 
Hayhurst,    E.    R.,    on   carbon     bisulphide 

poisoning,  35-42 
Hayhurst,  E.  R.,  on  carbon  dioxide  asphyxia 

in  silos,  672 
Hayhurst,  E.  R.,  on  carbon  dioxide  poison- 
ing in'  silos,  672 
Haj'hurst,  E.  R.,  on  examination   of    100 

able-bodied  painters,  116 
Hayhurst,  E.  R.,  on  explosives,  555 
Hayhurst,    E.    R.,    on    industrial     health 

hazards,  16,  785 
Hayhurst,  E.  R.,  on  lead  poisoning,  512, 

517 
Hayhurst,  E.  R.,  on  mirror  plating,  529 
Hayhurst,  E.  R.,  on  petroleum  workers,  547 
Hayhurst,  E.  R.,  on  rubber  workers,  505- 

Sii 
Hayhurst,  E.  R.,  on  steel  workers,  593 
Hayhurst,   E.    R.,   on   stone    and    marble 

workers,  627 
Hayhurst,  E.  R.,  on  varnish  industry,  551 
Hazen,  Dr.  Henry  H.,  xv 
Hazen,  H.  H.,  on  skin  diseases,  16 
Hazen,  Hird  and  Verrill,  15 
Head,  272,  273,  274 
Head,  Henry,  on   examination  of  patient 

with  writers'  cramp,  282-283 
Head,  on  hammerman's  cramp,  287 
Head,  on  occupation  neuroses,  270,  etc. 
Heath,  F.  C,  39 

Hedinger,  on    hearing  in  locomotive  engi- 
neers, 712 
Heim,  132 

Heim,  on  benzol  or  benzene,  140 
Hein  and  Herbert,  on  felt  hat  workers,  530 
Heinzerling  and  Lewin,  on  hatters,  531 
Hektoen  and  Reismann,  on    post-mortem 
findings  in  carbon  monoxide  poisoning, 
57 
Helbig,  on  the  health  of  match  makers,  149 
Heller,  130 

Heller,  on  caisson  disease,  188 
Hencke,  Karl,  on  mercury  workers,  529 


INDEX    OF    AUTHORS 


883 


Hencke,  Karl,  on  tobacco  workers,  697 

Henderson,  C.  R.,  on  labor  and  health 
boards,  S55 

Hensen,  Bockendahl  and  PoUak,  on  causes 
inducing  irritation  of  the  nasal  and 
nasopharyngeal  mucous  membrane, 
348 

Hermanni,  on  chrome  workers,  541 

Herxheimer,  on  an  affection  which  he  called 
chlorine  acne,  364 

Herxheimer,  on  trade  eczema,  355 

Hesse,  on  foundry  dust,  595 

Higgins,  E.,  on  excessive  dust  in  mines,  784 

Hill,  on  the  bones,  etc.,  in  compressed-air 
illness,  198 

Hill,  on  caisson  disease,  188,  194,  195 

Hill,  on  compressed-air  illness,  197 

Hill,  on  lack  of  evidence  of  superiority  of 
the  ''stage"  method  of  decompression 
over  the  uniform  decompression,  207 

Hill,  in  re  theories  on  compressed-air 
illness.  190 

Hill,  on  selection  of  men  suitable  to  work 
in  caissons,  202 

Hill,  on  shortening  of  decompression  as 
compared  with  Haldane's  tables,  208 

Hillairet,  on  asthma,  303 

Hippokrates,  vii 

Hird,  Dr.  John  D.,  xv 

Hird,  John  D.,  16 

Hirschberg,  on  glass  blower's  cataract,  638 

Hirt,  ix 

Hirt,  on  leaf  metal  workers,  584 

Hirt,  on  phosphorus  poisoning,  148,  149 

Hirt,  on  pneumonia  and  pulmonary  dis- 
eases, 427 

Hobbs,  Wm.  R.,  on  industrial  lead  poison- 
ing among  white  lead  workers,  106 

Hoessli,  on  detonation  experiments,  348 

Hoessli,  on  experiments  udth  sound  waves, 

347 
Hofifman,  Dr.  Frederick  L.,  xii 
Hoffman,  F.  L.,  on  button  workers,  644 
Hoffman,  F.  L.,  on  hatters,  532 
Hoffman,  F.  L.,  on  leaf  metal  workers,  584 
Hofifman,    F.    L.,    on     marble    and    stone 

cutters,  626 
Hofifman,  F.  L.,  on  mortality  from  cancer 

in  different  occupations,  390 
Hoffman,   F.  L.,  on    mortality  from  con- 
sumption in  dusty  trades,  14,  777,  787 
Hoffman,  F.  L.,  on  painters,  516 
Hofifman,  F.  L.,  on  paper  hangers,  635 


Hoffman,  F.  L.,  on  railing  accidents,  712 
Hofifman,  F.  L.,  on   tuberculosis  in  dusty 

trades,  777 
Holland,  legislation  in  1906  in  re   decom- 
pression in  prophylactic  treatment  of 
caisson  disease,  203 
Holmes,  J.  A.,  on  explosives,  565 
Holmes,  J.  A.,  on  mine  accidents,  618 
Holmes,  J.  A.,  on  mine  dust,  622 
Holt,  on  causes  of  impairment  of  hearing, 

346 
Holt,  on  impairment  of  hearing  of  copper- 
smiths, 345 
Holtzmann,  on  anthrax  in  leather  industry, 

573 

Holzer,  on  the  use  of  phosphorus  in  the 
making  of  miners'  lamps,  146 

Homann,  19 

Hope,  E.  W.,  on  anthrax  in  the  hide  in- 
dustry, 571,  575 

Hope  and  Hanna,  on  anthrax  in  man,  169 

Hoppe-Seyler,  on  spectroscopic  examina- 
tion, 61,  62 

Hoppe-Seyler,  on  theory  of  causation  of 
caisson  disease,  188 

Horand,  on  a  dermatosis  in  workers  in 
chestnut  wood,  365 

Horton,  F.  W.,  on  mine  accidents,  619 

Huber  and  Butler,  on  deaths  from  anthrax 
through  infected  meat,  170 

Hunt,  J.  R.,  on  drummers'  paralysis,  703 

Hutchinson,  Sir  Jonathan,  occurrence  of 
cancer    in     those     who     have     taken 


Illinois  Commission  on  industrial  diseases, 
on  carbon  monoxide  poisoning,  43 

Illinois  State  Commission,  on  occupational 
diseases,  15,  615,  xii,  xiii 

Imbert,  on  accidents  and  fatigue,  452 

Industrial  Hygiene  in  the  United  States, 

X,  XV 

International  Congress,  on  occupational 
diseases,  x 

J 

Jacobson,  272 

Jacquet  and  Jourdanet,  on  trade  eczema, 

355 
Jaksch,    v.,    on    dififerences    between    the 
petroleum  distillates  and  the  coal-tar, 
136 


884 


INDEX    OF    AUTHORS 


James,  on  treatment  of  amoebic  dysentery, 
177 

Japp,  H.  W.,  decompression  table  pre- 
pared by,  207,  208 

Japp,  in  re  "stage  decompression."  204, 
207,  208 

Japp,  on  compressed-air  illness,  191 

Javillin,  18 

Jeffries,  on  carbon  monoxide  poisoning,  46 

Jekle,  on  leaf  metal  workers,  584 

Jelliffe,  272,  273 

Jump,  H.  D.  and  Cruice,  J.  M.,  38,  39 

Johnson,  G.  W.,  on  petroleum  gas  poison- 
ing in  tunnel  workers,  622 


Kaposi,  on  tar  acne,  364 

Karasek,     Dr.    Matthew,    on    acclimating 

one's  self  to  carbon  monoxide  within 

certain  limits,  69 
Karasek,    Dr.   Matthew,   on    comparative 

tests  on  workmen  about  a  blast  fur- 
nace, 73 
Karasek,  on  metal  and  platinum,  616 
Karasek,  Dr.  Matthew,  on  observations  of 

clinico-pathological  examination  of  the 

blood,    in    chronic    carbon    monoxide 

poisoning,  70 
Karasek,  Dr.  Matthew,  on  toxicity  of  car- 
bon monoxide  gas,  47 
Kaup,   on  lead  in   the   air  of   the  drying 

ovens  in  a  white  lead  factory,  91 
Kaup,  on  painters,  420 
Kaup,  on  roof  tiling,  630 
Keays,  analyses  of  East  River  tunnel  cases 

of  compressed-air  illness  by,  200 
Keays,  F.  L.,  Japp,  H.,  and  McWhorter,  on 

compressed-air  illness,   188,   190-192 
Keays,  on  length  of  exposure   at  different 

pressures  in  caisson  and  tunnel  work, 

203 
Keays,    on    symptoms    of    compressed-air 

illness,  196 
Ketli,  130 
Key,  Cooper  A.,  on  explosives,  559,  563, 

564,  565,  566 
Kisskalt,  18 

Klink,  Jane  S.,  on  laundry  workers,  665 
Knauer,  18 

Knipers,  on  phosphorus  poisoning,  148,  151 
Knowles,  on  "Baker's  eczema,"  357 
Knowlcs,  on  dermatitis  in  bar  tenders  and 

liquor  (iealcrs,  360 


Knowles,  on  dermatitis  among  moving  pic- 
ture operators  and  photographers,  362 
Knowles,    on   dermatitis   in   printers    and 

workers  in  metals  and  minerals,  360 
Knowles,    on    dermatitis    in    workmen    in 

cotton  mills,  366 
Knowles,  on  diseases  of  the  skin,  354 
Knowles,  on  eczema  of  barbers,  357 
Knowles,  on  eczema  of  candy  makers,  358 
Knowles,  on  skin  affections  of  house  work- 
ers, 356 
Kober,  George  M.,  on  effects  of  diminished 

atmosphere  upon  health,  211— 217 
Kober,  George  M.,  on  etiology  and  proph- 
ylaxis of  occupational  diseases,   417- 
761 
Kober,  Dr.,  report  on  industrial  and  per- 
sonal hygiene,  xii 
Kobert,  15,  62 

Koch,  on  bacillus  anthracis,  158 
Kocher,  on  ''fragilitas  ossium,"  151 
Kocher,  on  treatment  of  phosphorus  poi- 
soning, 151 
Koelsch,  F.,  420,  427,  428,  450,  516,  517, 

536,  541,  680,  623 
Kolisko,  on  post-mortem  findings  in  carbon 

monoxide  poisoning,  57 
Kolle  and  Wassermann,  on  cases  of  anthrax 

in  Italy,  169 
Korschenewsky,  -on    constant    inhaling    of 

benzine  fumes,  139 
Korschenewski,  on  fatal  poisoning   by  pe- 
troleum products,  139 
Koschel,  on  the  effects  of  aviation  on  the 

pulse,  216 
Kostial,  on  tobacco  workers,  483,  697 
Kouindjy,  274 
Kraepelin,  279 
Krantz,   on   a   polyneuritis    following    gas 

poisoning,  66 
Krantz,  on  zinc  smelting,  502 
Kronenberg,  273 
Kunkel,  134 
Kunkle,  on  the   character  of  the  stools  in 

acute  mercurial  poisoning,  126 
Kussmaul,  on  copper    colored   redness  in 

mucous  membrane  of  mouth,  131 
Kussmaul,  on  industrial  mercurial  poison- 
ing, 129 


Labor   Legislation,    International    Associa- 
tion of,  419 


INDEX    OF    AUTHORS 


88. 


Laboulbene,  first  to  cite  cases  of  carbon 
bisulphide  poisoning  showing  cuta- 
neous ''taches  ecchymotiques,"  38 

Lampadius,  discoverer  of  carbon  bisulphide 
poisoning  in  1796,  35 

Lancereaux,  on  a  paralysis  of  the  leg,  due 
to  a  carbon  monoxide  neuritis,  66 

Lanel,  271,  273 

Lang,  Dr.  R.,  on  inhalation  and  absorption 
of  mercury,  132,  133 

Lang  and  Welander,  130 

Langlois,  J.  P.,  on  death  in  electric  shock, 
403 

Langlois,  J.  P.,  on  industrial  poisons,  418 

Langworthy,  C.  F.,  on  food,  473,  476 

Lanza,  A.  J.,  P.  H.  S.,  on  amoebic  dysentery 
and  hook-worm  in  miners,  625 

Lanza,  A.  J.,  on  dust  in  sheet-ground  mines, 
784 

Lanza,  A.  J.,  P.  H.  S.,  on  pulmonary  dis- 
eases in  zinc  miners,  623 

Lanza,  A.  J.,  P.  H.  S.,  on  temperature  in 
mines,  625 

Lappin,  R.  C,  15 

Latimer,  15 

Latta,  on  sciatica  in  locomotive  engineers, 
712 

Lander  and  Edwards,  Jr.,  19 

Laws,  C.  E.,  on  nitro-glycerine,  559 

Layet,  ix,  11 

Layet,  a  French  physician  mentions  in 
industries  in  which  lead  is  employed,  82 

Leclerc  de  PuUigny,  on  the  making  of  non- 
phosphorus  matches,  151 

Lee,  15 

Lee,  on  overexertion,  273 

Legge,  on  anthrax  in  man,  168,  169 

Legge,  T.  M.,  on  arsenic  poisoning,  3-14 

Legge,  T.   M.,  on  glass-workers'   cataract, 

33^-33^ 
Legge,  T.  M.,  on  the  health  of  brass  workers, 

27-34 
Legge,  T.  M.,  on  felt  hat  workers,  529-530 
Legge,  T.  M.,  on  lead  poisoning,  512    . 
Legge,  T.  M.,  on  variation  of  symptoms  of 

lead  poisoning,  126 
Legge  and  Goadby,  on  lead  poisoning  and 

lead  poisoning,  133 
Lehmann,  on  benzol  or  benzene,  140,  141, 

142 
Lehmann,  Prof.  K.  B.,  on  the  causation  of 

brass  founders'  ague,  31,  35,  36 
Lehmann,  on  chlorine  poisoning,  539 


Lehmann,   on    chronic    benzine  poisoning, 

139 

Lehmann,  on  a  difference  in  degree  between 
the  toxicity  of  benzol  and  benzene,  136 

Lehmann,  on  experimentations  with  differ- 
ent benzines,  137 

Lehmann,  on  hydrochloric  acid  fumes,  537 

Lehmann,  Professor  and  Saito,  on  inhala- 
tion of  lead  dust,  83 

Lehmann,  on  nicotine,  483 

Lehmann,  report  on  fatal  cases  of  gasoline 
poisoning,  139 

Lehmann,  Prof.  K.  B.,  on  the  toxicity  of 
zinc,  18 

Leipzig  Institute  of  Hygiene,  blood  exami- 
nations made  in  the,  84 

Leiser,  on  diseases  of  butchers,  690 

Leiser,  on  diseases  of  litographers,  614 

Leloir,  on  epidemic  of  folliculitis  and  peri- 
folliculitis in  spinners,  365 

Leloir,  on  skin  affection  in  flax  spinners  in 
Lille,  365 

Lenbuscher  and  Beelitz,  on  fatigue,  258 

Lenoir,  on  benzole  poisoning,  142 

Lepinay,  272,  273,  274 

L6ri,  272 

LetuUe,  on  paralysis  of  the  arms  and  legs  in 
industrial  mercurialism,  130 

Levi,  on  treatment  of  skin  affections  due 
to  chrome  compounds,  304 

Lewandowski,  272 

Lewin,  16 

Lewin,  on  affections  of  the  skin  of  workers 
in  silver,  353 

Lewin,  on  arsenic  poisoning,  531 

Lewin,  on  chronic  benzine  poisoning,  139 

Lewin,  on  fatal  cases  of  benzine  poisoning» 

139 
Lewin,  on  general  and  cutaneous  poisoning 

by  petroleum,  367 
Lewin,  on  intoxication  from  inhalation  of 

fumes  of  benzine,  138 
Lewin,  on  nitrous  fumes,  538 
Lewin,  on  skin  lesions  of  employees  in  the 

American  oil  country,  140 
Lewin,  on  the  to.xic  action  of  coal  tar  on  the 

nervous  system,  136 
Lewy,  on  phosphorus  poisoning,  148 
Leyden,    on    mercurial   polyneuritis    after 

mercury  inunctions,  130  • 

Leymann,  on  diseases  of  chemical  workers, 

535,  538' 
Leymann,  on  dinitrophenol,  545 


886 


INDEX    OF    AUTHORS 


Libin,  on  carbon  monoxide  psychoses,  64 

Libin,  on  post-mortem  findings  in  carbon 
monoxide  poisoning,  57 

Lindermann,  on  diseases  of  miners,  622 

Lindermann,  on  nystagmus,  624 

Linenthal,  H.,  on  the  early  diagnosis  of  lead 
poisoning,  96-101 

Linenthal.  H.,  on  garment  workers,  660 

Linenthal,  H.,  on  lead  poisoning,  early  diag- 
nosis of,  96-101 

Linenthal,  H.,  on  prevention  of  all  efifects 
from  industrial  processes,  861 

Liversuge,  J.  F.  and  Knapp,  A.  W.,  experi- 
ments on  influence  of  water  on  new 
lead  pipe,  76 

Lloyd,  Dr.  J.  H.,  xiii 

Lloyd,  J.  H.,  on  felt  hat  workers,  530 

Loewy  and  Placzek,  on  psychic  factors  in 
aviation,  214 

Lorinser,  on  phosphorus  matches,  146 

Lorinser,  on  phosphorus  poisoning,  148 

Lorinser,  Dr.,  report  of  first  authentically 
recorded  case  of  industrial  phosphorus 
poisoning,  1838,  155 

Loth,  on  diseases  of  farmers  and  gardeners, 
670 

Lovejoy,  O.  R.,  on  exclusion  of  minors  from 
dangerous  occupations,  847 

Luce  Rey  Vincent,  on  industrial  aniline 
poisoning,  570 

Luig,  Bruno,  37 

Lynch,  on  exercise,  470 


M 


Macaulay,  Dr.  D.,  on  a  form  of   tubercu- 
losis in  gold  miners,  230 
Mackenzie,  on  affections  of  the  skin,  367 
Mackenzie,  James,  on  writers'  cramp,  285 
Macleod,  on  caisson  disease,  188 
Mager,  on  caisson  disease,  188 
Magitot,  on  phosphorus  poisoning,  149 
Magnus,  on  formula,  329 
Magnus,  on  injuries  to  the  eye,  323 
Mahu,  on  phosphorus  poisoning,  149 
Maljeau,    on    reports    of    poisoning    from 

arseniureted  hydrogen  gas,  213 
Mann,  Dr.  Dixon,  10 
Manning,  W.  H.,  on  printers,  612-613 
Mantegazza,  on  dermatitis  among  workers 

in  rice  fields,  369 
Margoniner,  on  laundry  workers,  665 
Marie,  Pierre,  38 


Matshall,  Arthur,  on  explosives,  557,  561, 
563,  564,  566 

Marx,  on  effect  on  ear  of  intense  sounds  ol 
high  pitch,  348 

Massachusetts  General  Hospital,  recorded, 
cases  of  lead  poisoning  in,  98-100 

Massachusetts  General  Hospital,  record 
of,  on  the  first  recorded  case  of  phos 
phorus  poisoning  in  America,  146 

Massachusetts  State  Board  of  Health,  538, 
576,  597,  614,  627,  636,  651,  635,  658, 
659,  660,  663,  681 

Massachusetts  State  Board  of  Health, 
publications  on  factory  sanitation,  xii 

Massaut,  273 

Matzke witch  et  al.,  18 

McCurdy,  Douglas,  on  aviators,  214,  215 

McCurdy,  Douglas,  on  danger  in'  sudden 
descents,  ballooning,  215 

McCurdy,  Douglas,  on  effects  of  exposure 
in  ballooning  to  extreme  cold,  214 

McLean,  on  gangrene  following  gassing, 

McSweeney,  E.  F.,  on  industrial  incidence 
of  tuberculosis  in  Massachusetts,  484 

McWhorter,  on  caisson  disease,  193 

Maynard,  G.  G.,  on  statistics  of  miners 
phthisis,  785 

Meige,  272,  274 

Mendes  da  Costa,  on  cases  of  lupus  in 
which  X-ray  was  used,  393 

Merzbach,  on  occupational  dermatoses,  356 

Mettler,  272,  274 

Meyhoffer,  on  cataract  in  glass  blowers,  638 

Meynert,  Theodor,  273 

Michaelis,  18 

Mitchell,  J.  K.,  on  petroleum  skin  affec- 
tions, 548 

Mohr,  272 

Moir,  E.  W.,  on  compressed-air  illness,  192 

Molinari,  Ettore,  on  copper  and  zinc,  15 

Molinari,  Ettore,  on  uses  for  carbon  bi- 
sulphide, 35,  36 

Mosny,  88 

Mosso,  on  fatigue,  254 

Mott,  F.  W.,  88 

Mott,  F.  W.,  on  carbon  monoxide  psy- 
choses, 64 

Mott,  F.  W.,  on  post-mortem  findings  in 
carbon  monoxide  poisoning,  57 

Mott  and  Schuster,  on  cause  of  death  in 
electric  shock,  410 

Muller,  on  catarrh  of  the  mucous  mem- 
brane, 296 


INDEX    OF    AUTHORS 


887 


Muller,   on   the   danger   from    lead   on   a 

man's  hands,  114 
Muller,  on  lead  in  the  air  of  a  lead  smelting 

works,  91 
Munroe,  Prof.  Charles  E.,  xv 
Munroe,   Charles  E.,  on    explosives,   554, 

555i  557>  558,  564 
Munson,  E.  L.,  U.  S.  Army,  on   artificial 

lighting,  438 
Murgia,  on  solubility  of  lead  sulphide  and 

absorption  by  the  body,  113 
Murray,  \V.,  on  chandelier  makers,  496 


N 


Narsarow,   on    mortality  in   infections   of 

malignant  anthrax,  170 
Xasmith  and  Graham,  on  observations  of 

changes  in  blood  of  animals  in  chronic 

carbon  monoxide  poisoning,  70 
National     electric     light     association,     on 

resuscitation  from  electric  shock,  413 
National  Safety  Council,  xiii 
Neisser,  Dr.  E.  J.,  xii 

Neisser,  E.  G.,  on  benzine  cleaning,  14,  550 
Neisser,  E.  G.,  on  explosives,  556 
Neisser,  E.  G.,  on  pearl  button  workers,  644 
Neisser,  E.  G.,  on  poisonous  dyes,  656 
Nieszytka,  on  diseases  of  miners,  622,  623 
Nicolaier,  on  "foot  and  mouth  disease"  in 

man,  372 
Nothnagel,  on  occupation  neuroses,  273 


O 


Oestreicher,  on  causes  of  eczema,  361 

Off  ret,  Alfred,  19 

Ogle,  Dr.,  on  coal  miners,  623 

Ogle,  Dr.,  on  tin  miners,  604 

Ogston,    on   dermatitis    in    men    working 

crude  paraffin,  367 
Ohio  State  Board  of  Health,  16,  595 
Oldendorff ,  ix,  11 
Oliver,  Sir  Thomas,  23 
Oliver,  Sir  Thomas,  11,  418,  421,  422,  429, 

498,  545,  555,  559,  584,  585,  604,  605, 

610,  627,  631,  636,  637,  653,  706 
Oliver,  on  altitude  of  copper  miners,  211 
Oliver,  on  anthrax  in  man,  168 
Oliver,  Sir  Thomas,  on  dangerous  trades,  ix 
Oliver,  Sir  Thomas,  on  dust  and  fumes  as 

foes  of  industrial  life,  787 


Oliver,  Sir  Thomas,  on  electrical  injuries 

and  electrical  shock,  402-414 
Oliver,    Sir  Thomas,   on    lead   poisoning, 

75-95 
OUver,    on     lymphangitis     occurring     in 

workers  in  sugar  refineries,  359 
Oliver,  on  phosphorus  poisoning,  148,  149 
Oliver,    Sir     Thomas,    on    the    poisonous 

effects     of    carbon     bisulphide     upon 

animals,  37,  39 
Oliver,  on  rapidity  of  collapse  in  pulmonary 

anthrax,  170 
Oliver,    Sir   Thomas,  on   the   report  of  a 

woman    found     dead     from     carbon 

monoxide  poisoning,  58,  59 
Olmsted,  D.  H.,  xi,  13 
O'Mallc}',  on  carbon  monoxide  psychoses,  64 
Oppenheim,  on  occupation  neuroses,  270 
Oppenheim,  273,  274 
Oppenheim,    on   definition    of    occupation 

neuroses,  270 
Oppenheim,  on  occupation   neuroses,  272, 

275 

Ordway,  Thomas,  on  cancer  and  occupa- 
tion, n;-ray  and  radium,  380-401 

Osier,    on    danger    of    cancer     in    cobalt 
miners,  389 

Osier,  on  mortality  in  infections  of  malig- , 
nant  anthrax,  170 

Osier,    record    of    deaths     from     anthrax 
through  infected  meat  reported  by,  170 

Osier,  on  symptoms  of  anthrax  in  man,  170 

Osier,    on   unconsciousness   in   pulmonary 
anthrax,  170 

Ovington,  E.  L.,  on  aviation,  214 

Ovington,  Earle  L.,  on  high  fl>'ing  in  bal- 
looning, 214, 215 


Parke's  process  of  vulcanizing  carbon  bi- 
sulphide, 36 

Parsons,  17 

Parsons,  J.  Franklin,  on  debate — whether 
heat  or  light  rays  caused  cataract — 
physiological  side,  336 

Partridge,  Reuben,  on  phosphorus  matches, 

153 
Patterson,  Dr.,  on  the  use  of  the  Clague- 

Oliver   method   of   the   treatment   for 

lead  colic,  94 
Patissier,  ix 
Pattisier,  11 


INDEX    OF   AUTHORS 


Panwitz,  on  dust  in  printing  establish- 
ments, 6io 

Patterson,  Maty  M.,  on  fish  curing  in- 
dustry, 689 

Paul,  W.  E.,  on  typewriters'  cramp,  286 

Paul,  W.  E.,  on  writers'  cramp,  275 

Pazen,  called  attention  to  carbon  bisulphide 
as  an  occupational  poison,  35 

Pearson,  H.  C,  35,  41 

Peel,  Sir  Robert,  viii 

Peel,  Robert,  on  labor  laws,  10 

Peri,  Dr.,  on  professional  pathology  of 
dramatic  artists,  774 

Perlen,  on  dust  in  relation  to  tuberculosis, 
427 

Pernet,  on  skin  affections,  371 

Perrin,  37 

Petard,  on  balloon  flights,  211 

Peterson,  recovery  from  three  cases  of 
mania  caused  by  carbon  bisulphide 
reported  by,  41 

Petkewitch,  on  constant  inhaling  of  ben- 
zine fumes,  139 

Phillips,  Alonzo,  on  phosphorus  friction - 
matches,  153 

Picraccini,  on  female  tobacco  workers,  698 

Picraccini,  on  painters,  518 

Piender,  C.  A.,  23 

Pieraccini,  on  the  danger  of  necrosis  in  the 
preparation  of  phosphorus,  145 

Pieraccini,  on  fatigue,  257 

Pieraccini,  on  phosphorus  poisoning,  149 

Pigeon,  L.,  39 

Pirrie,  R.  Reid,  on  high  explosives  and 
nitro-glycerine,  566 

Pitchford,  Watkins,  Dr.,  on  dust,  438-440 

Plesch,  on  compressed-air  illness,  191 

Poincare,  37 

Pol  and  Wattelle,  earliest  investigation  of 
caisson  disease  undertaken  by,  187 

Pol  and  Wattelle,  theories  on  compressed- 
air  illness  advanced  by,  190 

PoUender,  on  bacillus  anthracis,  158 

Poncet,  Albertin,  Chaussende,  On  inflam- 
mation of  nails  occurring  in  confec- 
tioners, 358 

Poore,  G.  Vivian,  on  occupation  neuroses, 
270 

Poore,  de  L^pinay  and  Riseau,  on  pianists' 
cramp,  287 

Poore,  Vivian,  on  telegraphers'  cramp,  286 

Poore,  Vivian,  on  writers'  cramp,  275,  276, 
277 


Poore,  Vivian,  on  writers'  cramp,  281 
Popoff,  see  manganese,  121 
Popoff,  on  zinc  poisoning,  498 
Popper,  on  diseases  in  tanners,  572 
Pope,  Dr.,  on  mercury  poisoning,  521 
Porter,  on  protection  and  care  in  working 

with  the  X-ray,  394 
Potts,  on  a  case  of  "encephalitis"   due   to 

gasoline  poisoning,  138 
Pratt,  E.  E.,  xiii 

Pratt,  E.  E.,  on  lead  poisoning,  15,  517 
Pratt,  Edward  Ewing,  report   on  cases  of 

lead  poisoning  in  New  York  City,  by, 

103,  104, 116 
Preti,  Dr.,  on  chemical  changes  in    over- 
exertion, 770 
Prettin  and  Liebkind,   on    emphysema  in 

glass  blowers,  638 
Prevost  and  Battelli,  on  cause  of  death  in 

electric  shock,  409 
Prevost  and  Battelli,  on  death   in  electric 

shock,  403 
Prevost  and  Battelli,  on  voltage,  406 
Price,  Dr.  George  M.,  xiii,  xiv 
Price,  Dr.  George  M.,  on  modern  factory, 

12,  IS 
Price,  Dr.  George  M.,  on  garment  workers, 

660 
Priestley,  in  re  theories  on  compressed-air 

illness,  190 
Purdon,   on   a  peculiar    form  of   acne   on 

forearms   of  workers  in  linen  mills  of 

Belfast,  365 
Putzey,  Felix,  418 
Putzeys,  on  lighting,  437 
Pye-Smith,  occurrence  of  cancer  in  persons 

employed  in  "sheep-dip"  factories,  5 


R 


Ram,  G.  Scott,  on  electrical  accidents  in 

Great  Britain  in  1913,  402 
Ramazzini,  Prof.,  vii 
Ramazzini,  Bernado,  9,  625 
Rambousek,  J.,  18,  36,  494,  502,  538,  539, 

540,  543,  559>  628,  637 
Rambousek,  as  to  cases  of  lead  poisoning 

among   10,000   Bohemian  miners  and 

smelters,  113 
Rambousek,  on  benzol  or  benzene  poisoning 

140,  141 
Rambousek,  on  the  toxic  action  of  coal  tar 

on  the  nervous  system,  136 


INDEX    OF    AUTHORS 


889 


Raoult  et  Breton,  Jr.,  16 

Ravenel,  on  anthrax,  372 

Ravenel,  on  anthrax,  572 

Ravenel,  on  anthrax  in  man,  169 

Raymond,  273 

R6my  and  Broca,  on  eczema  of  workers  in 

sugar  refineries,  358 
Renk, 134 

Reymond,  on  accidents  of  aviation,  213 
Reymond,  on  diseases  of  aviators,  216 
Reymond,  on  effects  of  aviation  on  the  ear, 

-12 

Reymond,  on  hygiene  of  airmen,  212 

Ribbert,  on  cancer,  381 

Richardson,  on  "the  bichromate   disease," 

362 
Riche,  on  phosphorus  poisoning,    150 
Riegel,  on  blood  pressure  during  colic    of 

lead  poisoning,  86 
Robinson,  D.  E.,  on  industrial  tuberculosis, 

504 
Robinson,     W.,     on     cataract    of     bottle 

finishers,  332 
Robinson,  W.,  on  character  of  cataract,  332 
Robinson  W.,   results  of    examination  of 

men  in  glass  works  who  were  suffering 

from  cataract,  333 
Roepke,  on  the  effect  of  dust  on  miners,  344 
Rogers,  C.  T.  Graham  and  Vogt,  John  H., 

on  tests  to  determine  the  presence  of 

lead  in  the  air,  104,  105 
Rogers,  Dr.  C.  T.  Graham,  xiii 
Rogers- Graham,  C.  T.,  15,  439 
Rogers,  Leonard,  on   treatment  of  amoebic 

dysentery  with  emetine,  177 
Rohrer,  15 

Ropke,  F.,  428,  591,  592,  601 
Ropke,  on  causes  of  impairment  of  hearing, 

346 
Ropke,  on  pathology  of  phosphorus  poison- 
ing, 148 
Rose,  on  hook-worm  disease,  671 
Rosenfield,  on  tobacco  workers,  698 
Rossle,  on  cement  and  lime  workers,  632 
Ross,  Sir  Ronald,  175 
Roth,  ix 
Roth,  E.,  II,  439,  450,  452,  505,  546,  599, 

643,  644,  689,  697 
Roth,  on  fatigue,  259 
Roth,  on  the  toxic  action  of  coal  tar  on  the 

nervous  system,  136 
Royal  Commission  in  England  and  Wales, 

report  of,  1901,  12 


Rubner,  E.,  on  accidents,  452 
Rubner,  E.,  on  female  labor,  449 
Rubner,  Professor  and    Smith,  Angus,  on 
safety  limit  of  lead  in  drinking  water, 

91 
Rudler,  272 
Russell,    Dr.    John,    found     basophiles   in 

pottery  workers,  84 


Sacher,  18 

Sachur,  on  a  case  illustrating  distinct  idio- 
syncrasy to  react  with  mercury,  132 

Salant,  W.,  on  tin,  605 

Santesson,  on  benzol  or  benzene  poisoning, 
140, 142 

Savill,  274 

Schablowsky,  on  industrial  smallpox,  425, 
578 

Schamberg,  on  "grain  itch,"  375 

Schereschensky,  J.  W.,  U.  S.  Public  Health 
Service,  14 

Schlockon,  on  a  peculiar  disease  among 
workers  in  a  zinc  mine,  cf .  manganese, 
119 

Schmidt,  P.,  on  the  diagnosis  of  plumbism, 

84 
Schonhals,  on  fatigue,  258 
Schrotter  (von),  on  aviation,  211 
Schrotter  (von),  on  balloon  gas  poisoning, 

213 
Schuler,  on  acrolein,  610 
Schuler,  on  morbidity  in  dusty  trades,  439 
Schuler,  on  printers,  609 
Schultz,  on  nitrous  fumes,  538 
Schumacher,  J.  X.,  on  analyses  of  carbon 

monoxide,  69 
Schumacher,  J.  X.,  on  the  composition  of 

exhaust  gas,  55 
Schutte,  on  arsenic  poisoning,  531 
Schiitte,  on  hatters,  532 
Schwab,  on  neurasthenia,  448 
Schwab,  on  garment  workers,  661 
Scott,  Dr.  Alex.,  on  dementia  and   acute 

mania  from  carbon  monoxide  poisoning, 

64 
Scott,  Ernest,  Dr.,  on  carbon   dioxide  as- 
phyxia in  silos,  672 
Scott,  Ernest,  on  carbon  dioxide  poisoning 

in  silos,  672 
Scurfield,  Dr.,  on  steel  grinders,  600 
Seeligmiiller,  274 


890 


INDEX    OF    AUTHORS 


Segar,  on  "foot  and  mouth  disease"  of  man, 

372 
Selkirk,  on  lime  workers,  623 
Selling,  on  benzol  or    benzene  poisoning, 

140-143 
Senn,  on  chinon,  546 
Sharp,  on  brass  foundries,  492 
Sharp,  W.  H.,  on  petroleum,  548 
Sibelius,  on  carbon  monoxide  psychoses,  64 
Siebe,  first  diving  helmet  supplied  by,  187 
SUberstein,  on  printers,  609,  613 
Silberstem,  on  caisson  disease,  188 
Smith,    A.    H.,   theory   on  compressed-air 

illness  held  by,  190 
Smith,  Angus  and  Rubner,  on  safety  limit 

of  lead  in  drinking  water,  91 
Smith,  Lorrain,  theory  on  compressed-air 

illness  advanced  by,  190 
Snell,  Simeon,  on  harmful  effects   of   ex- 
posure to  electric  light  and  to  electric 
welding,  412 
Snell,  theory  on  compressed-air  illness  ad- 
vanced by,  190 
Soloman,   H.   C,  on  occupation  neuroses, 

270-295 
Solly,  274 
Sommerfeld,  ix 
Sommerfeld,  Dr.  Theo.,  11,  418,  427,  598, 

609,  615 
Sommerfeld  &  Fischer,  38 
Sonnenschein,  on  fatal  poisoning  by  inhala- 
tion of  carbon  monoxide  gas,  46 
Soper,  Dr.  G.  A.,  on  subway  dust,  715 
Southard,  E.   E.,  on  occupation  neuroses, 

270-295 
Spietschka,  on  skin  affections  of  workers  in 

enamel  manufactories,  375 
Spitzka  and  Raschi,  on  condition  of  brain 

after  death  from  electric  shock,  410 
Sprenger,  Dr.,  on  file  cutters,  602 
Squire,  Miss,  on  label  licking,  668 
Starr,  272 

Stein,  on  disease  of  nail,  374 
Stephani,  Dr.,  on  tobacco  workers,  697,  698 
Stern,  on  dermatoses  of  musicians,  370 
Sternberg,  Dr.,  on  carpenters,  676 
Sternberg,  Dr.,  on  shoemakers,  657 
Sternberg,  Dr.,  on  type  founding,  610 
Stevens,  Dr.,  on  the  internal  administration 
of  calcium  permanganate  for  lead  colic, 

93 
Stevens,  Geo  A.,  on  printers,  609 
Stitt,  E.  R.,  on  acute  plumbism  from  ship 

painting,  116 


Stitt,  E.  R.,  on  harmfulness  of  red  lead,  q.v., 

79 

Stitt,  E.  R.,  U.  S.  Navj',  on  red  lead  poison- 
ing, 79 

Stierlin,  on  carbon  monoxide  psychosis,  64 

St.  Louis  bridge,  cf.  compressed-air  illness, 
188 

Stokes,  C.  F.,  U.  S.  Navy,  on  eye  strain,  706 

Stokes,  C.  F.,  U.  S.  Navy,  on  gas  poisoning, 
706 

Stokes,  C.  F.,  U.  S.  Navy,  on  overtraining, 
704 

Stokes,  C.  F.,  U.  S.  Navy,  on  searchlights, 
706 

Strasser,  on  type  cases,  611 

Strassman  and  Schultz,  on  post-mortem  ef- 
fects of  carbon  monoxide,  58,  59 

Strumpell,  272,  274 


Tatham,  Dr.,  on  copper  workers,  499 
Tatham,  Dr.,  on  fide  cutters,  602 
Tatham,  Dr.,  on  gunsmiths,  602 
Tatum,    Prevost-Batelli,    on     theories    of 

death  in  electric  shock,  403 
Taylor,    on     scientific    management    and 

fatigue,  267 
Tavera,  first  studied  the  blood  changes  in 

carbon  bisulphide  poisoning,  35 
Teleky,  Dr.  L.,  on  health  of  wage-earning 

children,  847 
Teleky,  on  industrial  strain  in  children,  851 
Teleky,  on  the  extension  of  suppuration  in 

phosphorus  poisoning,  148,  150,  151 
Teleky,  Ludwig,  on  list  of  industrial  poi- 
sons, 418 
Teleky,  Dr.  Ludwig,  on  mercury  poisoning, 

126-135 
Teleky,  Ludwig,   on  mercury  workers,  521, 

534 

Teleky,  Ludwig,  on  pearl-button  workers, 
644 

Teleky,  on  phosphorus  poisoning,   148,  151 

Teleky,  on  the  presence  of  basophiles  in  the 
blood  of  healthy  persons,  84 

Teleky,  on  safety  limit  of  lead  in  drinking 
water,  91 

Thackrah,  C.  Turner,  ix,  11 

Thackrah  (cited  by  Arlidge),  23 

Thibierge  and  Jacquet,  on  skin  inflamma- 
tions, 355 

Thiersch  and  Waldeyer,  on  cancer,  381 

Thomas,  J.  J.,  272,  273 


INDEX  OF  AUTHORS 


891 


Thomas,  274 

Thompson,  Dr.  W.  Oilman,  xiv 

Thompson,  Dr.  W.  G.,  15 

Thompson,  W.  G.,  on  anthrax  in  carpet 
workers,  653 

Thompson,  W.  G.,  on  arsenic  in  leather 
dressing,  574 

Thompson,  W.  G.,  on  arsenic  in  shellac,  551 

Thompson,  on  cases  of  anthrax  in  man  re- 
ported in  England  in  1910  and  1911, 
169 

Thompson,  W.  G.,  on  furriers,  577 

Thompson,  Dr.  W.  Gilman,  on  hyper- 
pyrexia in  carbon  monoxide  coma,  61 

Thompson,  on  mortality  in  infections  of 
malignant  anthrax,  170 

Thornton,  Dr.,  on  mine  dust,  621 

Thorpe,  Sir  Edward,  on  the  substitution  of 
leadless  for  lead  glazes,  82 

Thorpe,  T.  E.,  on  phosphorus,  147 

Tolman,  Wm.  H.,  13 

Tracy,  Roger  S.,  on  female  tobacco  workers, 
698 

Trask,  J.  W.,  on  notification  of  occupa- 
tional diseases,  820 

Treves,  on  fatigue,  259 

Triger,  on  compressed-air  illness,  etc.,  187 

Turner,  Dr.  G.  A.,  on  a  form  of  tubercu- 
losis in  gold  miners,  230 

Tylecote,  on  felt  hat  workers,  530 

Tyzzer,  E.  E.,  on  cancer  and  occupation; 
.T-ray,  and  radium,  380-401 


U 


Uffelmann,  J.,  on  diseases  in  rag  and  paper 
workers,  667 

Uffelmann,  J.,  on  washerwomen,  664 

United  States  Bureau  of  the  Census,  on 
reported  fatal  cases  of  anthrax,  169 

United  States  Bureau  of  Labor,  12,  454,  586, 
588,  589,  590,  595 

United  States  Bureau  of  Labor,  cases  of 
phosphorus  poisoning,  among  match 
factory  operatives  reported  by,  155 

United  States  Bureau  of  Labor  Mines,  561, 
619,  620 

United  States  Census  Abstract,  13th,  15,  16 

United  States  Department  of  Agriculture, 
report  in  1904  on  arsenic  in  wall  pa- 
pers, 3,  4 

United  States  Department  of  Labor,  Pub- 
lications of  xi-xiii 


United  States  National  Museum,  14 

United  States  Public  Health  Service,  14, 
623,  625,  661 

United  States  Public  Health  Service,  Divi- 
sion on  industrial  hygiene  of,  xiv 

United  States  Navy,  occupational  disa- 
bility in,  719 


Vallardi,  Dr.,  on  phosphorus,  771 

Valsalva,  on  compressed-air  illness,  195 

Vance,  272 

Vernon,  on  compressed-air  illness,  191,  195 

Verrill,  Mr.  Charles  H.,  xv,  16 

Verrill,  C.  H.,  on  the  United  States  Labor 
Bureau,  856 

Villaret,  on  phosphorus  poisoning,  148 

Vogt,  272,  274 

Von  Bibra,  on  phosphorus  poisoning,  150 

Von  Eichen,  on  experiments  with  sound 
waves,  347 

Von  Hansemann,  on  cancer,  382 

Von  Jagic,  on  X-ray  workers,  640 

Von  Jaksch,  on  the  absence  of  pathological 
findings  in  manganese  poisoning,  123 

Von  Jaksch,  on  description  of  symptoms 
of  manganese  poisoning,  120 

Von  Jaksch,  on  phosphorus  poisoning  from 
acetylene  gas,  146 

Von  Schrotter,  on  caisson  disease,  188 

Von  Schrotter,  on  carbon  monoxide  poison- 
ing in  ballooning,  213 

Von  Schrotter,  on  decompression  in  re 
caisson  and  tunnel  works,  208 

Von  Schrotter,  on  temperature  in  high  ele- 
vations, 213 


W 


Walchholz  and  Lenenberger,  post-mortem 
experiments  by,  58,  62 

Walker,  John,  on  the  discovery  of  the  igni- 
tion of  phosphorus  by  friction,  153 

Walkhoff,  on  effect  of  radium  rays,  398 

Wassermann  and  Kolle,  on  cases  of  anthrax 
in  Italy,  169 

Wassermann  reaction,  among  lead  workers, 

90 
Wegner,  on  phosphorus  poisoning,  150 
Weichardt,  on  to.xins  of  fatigue,  273 
Weidner,  on  carbon  monoxide  psychoses,  64 


892 


INDEX    OF    AUTHORS 


Weiss,  G.,  on  cause  of  death  in  electric 
shock,  408 

Welandee,  130 

Wengler,  131 

Weyl,  20,  21 

Weyl,  Theodor,  ix,  11 

Weyl,  Theodor,  on  chemical  workers,  535 

Weyl,  Theodor,  on  petroleum  workers,  548 

Weyl,  Theodor,  on  phenol,  544 

Whipple,  G.  W.,  on  the  fallacies  of  statis- 
tics, 789 

White,  Henry,  xi 

White,  on  cases  of  deep-seated  dermatitis, 
362 

White,  on  causes  of  eczema  of  candy  and 
sugar  workers,  358 

White,  James  C,  on  dermatitis   venenata, 

351 
White,  James  C,  on  effect  of  chlorine  gas 

on  the  skin,  364 
White,  on  effect  on  workmen  engaged  in 

manufacture  of  lacquer,  368 
White,  on  vanilla  poisoning,  368 
White  and  Sellers,  on  anUine  poisoning,  546 
Whitehaven,  England,  deaths  from  carbon 

monoxide  poisoning  in  a  mine  at,  56 
Whittelsey,  S.  S.,  on  labor  legislation,  13 
Whittelsey,  Miss  S.  S.,  on  Massachusetts 

labor  legislation,  xi 
Wichern,  description  by,  of  accident  in  a 

benzine  tank,  138 
Williams,  T.  A.,  on  occupation  neuroses, 

272 
Willoughby,  Wm.  F.,  xi,  13 
Wilson,  J.  C,  assistant  surgeon  U.  S.  P.  H. 

S.,  on  industrial  tuberculosis,  504 


Winslow  and  Brown,  microbes  in  air,  779 
Wittgen,  on  cement  workers,  633 
Wittmarck,    on   effect  on  ear  of  intense 

sounds  of  high  pitch,  348 
Wolf,  on  severe  cases  of  mercurial  poisoning, 

344 
Wollner,  on  bronze  workers,  498 
Wreden,  on  the  instances  of  mycosis  of  the 

external  canal,  341 
Wright,  Carroll  D.,  12,  14 
Wiirdemann,  on  formula,  330 
Wurthenan,  on  drummers'  paralysis,  703 
Wyss,  Unna  and  Wolbach,  on  X-ray  der- 
matitis, 395 


Yoshii,  on  result  of  detonation  with  middle- 
ear  injury,  348 
Young,  Dr.,  on  African  box  wood,  675 


Zadek,  15,  16,  19,  24 

Zadek,  on  copper  workers,  500 

Zaugger,  Heinrich,  on  carbon  monoxide 
psychoses,  64 

Zellner  and  Wolff,  on  skin  affections  of 
printers  employed  by  Berlin  news- 
papers, 361 

Zellski,  63 

Zimmermann,  on  a  fatal  case  of  benzine 
poisoning,  139 

Zuntz,  on  gaseous  distention  of  intestines 
due  to  diminished  atmospheric  pres- 
sure, 212 


INDEX  OF  SUBJECTS 


Ablutions  and  baths,  463 

Abnormal  atmospheric  conditions,  436 

light  conditions,  436 
Abortions,  in  wives  of  varnishers  (Milan), 

771 
Accidents  and  alcohol,  480 
and  fatigue,  452 
and  injuries,  451,  586,   588,  589,  592, 

595,  712 
and  night  work,  591 
and  prevention  of,  452 
in  steel  plants,  summary  of,  590 
Accumulators,  497,  528 
Aceto-arsenite  of  copper,  3 
Acetylene      gas,      phosphorus      poisoning 

through  the  use  of,  145 
Acrocj^anosis,  282 
Acrolein,  551 
Acroparaesthesia,  285 
Actinomycosis,  424 

Acute  mercurial  poisoning,  manifestations 
of,  in  intestinal  tract,  126 
X-ray  dermatitis,  cause  of,  391 
Administrative  Boards,  methods,  869 
Aerasmia  {see  Compressed-air  illness). 
Aeropathy  {see  Compressed-air  illness). 
After-damp,  621 
African  boxwood,  675 
Agricultural  implements,  603 

pursuits,  injuries  to  the  eye  from,  308 
Air,  analysis,  779 
compressed,  809 
microbes  in,  779 
passages,  779 

irritant  action  of  salts  of  arsenic  on 

mucous  membrane  of,  5 
upper  {see  Nose,  mouth  and  throat). 
action  of  dust  on,  297 
preventive  measures  against  inha- 
lation of  dust,  298 
I.  respirator, 
space,  431 
Albuminuria    as     an    early    sign    of    lead 
poisoning,  87 


Alcohol,  effects  of,  480 
foe  to  workers,  774 
habit,  479 

and  accidents,  480 
Alcoholism,  277 
Alimentation,  473 
Altitudes,  high,  effects  of,  211 
Aluminosis,  438 

Amoebic    dysentery,   description  of  causa- 
tive parasite,  176 
diagnosis,  177 
emetine  in  treatment,  177 
pathogenesis,  176 
prophylaxis,  177 
Ammonite,  560 

Ammunition,  manufacture  of,  561-563 
Anaemia,  acute  secondary,  237 
chronic,  238 

in  chronic  interstitial  nephritis,  248 
Aniline,  545 

colors  {see  Nitrobenzene  process), 
manufacture  of,  with  the  use  of  arseni- 

ous  acid,  4 
poisoning  in  the  United  States,  570 
Anilinism,  546 

Ankylostomiasis,  legislation,  813 
Anthracene,  544 
Anthracosis,  218,  220,  438 
Anthrax — By  Langdon  Frothingham,  158- 

172 
Anthrax,  424 

bacillus,  1 58-16 1 
in  animals,  161-168 
diagnosis  of,  165,  166 
prevention  of,  166-168 
symptoms  of,  163-165 
in  man,  168-172 
diagnosis  of,  170 
legislation  to  minimize  the  danger  of, 

172,  812 
prevention  of,  171,  172 
symptoms  of,  169,  170 
treatment  of,  171 
Antimony  poisoning  {see  Zinc  asthma),  119 


893 


894 


INDEX    OF    SUBJECTS 


Appendicitis  and  lead  poisoning,  102 
Army,  U.  S.,  mortality  rates,  704 
Argyria,  580 

Arsenic,  effect  of  handling  hides  preserved 
with,  4 
how  obtained,  3 
irritant  action  of  salts  of,  4 
its  uses,  4 

occurrence    of   cancer   among    arsenic 
workers    and   persons    who    have 
taken  arsenic  for  a  long  period,  5 
poisoning  from  the  extraction  of,  5 
workers  in,  485-487 
Arsenical  ores,  smelting  of,  485 

poisoning,  cases  reported  to  the  Chief 
Inspector    of    Factories,   London, 
1900-1913,  5,  6 
from  consumption  of  beer  and  other 

articles,  12,  13 
in  relation  to  wall  papers,  4 
references,  14 
Arsenic  poisoning— By  T.  M.  Legge,  3-14 
manufacture  of  zinc  salts,  18 
references,  14 
recovery  process,  precautions   in    the 
process     of    de-arsenicating     sul- 
phuric acid,  6,  7 
salts  of  (cf.  emerald-green  industry), 
occupations  involving  danger  from 
arsenic  poisoning,  4-7. 
I.  arsenic  extraction  of;  2.  chem- 
ical  works;    3.    emerald   green, 
manufactures;  4.  hides,  sorting 
of;    5.   paint  and   color  works; 
6.  paint,  scraping  of;  7.  "sheep- 
dip,"  manufacture   of;   8.   shot 
making;   9.  smelting  of  metals 
(lead,  copper) ;  10.  tanning;  11. 
wall  paper,  manufacture  of;  12. 
white  arsenic,  unloading  of. 
symptoms  caused  by  dust  of,  5 
from  manufacture  of,  or  contact 
with,  in  spite  of  certain  precau- 
tions, 6 
"soot,"  3 

white,  cases  of  poisoning  from  the  un- 
loading of,  6 
Arsenious  acid,  485 

Arsenite  of  copper  in  the  preparation  of 
artificial  flowers  and  wall  papers, 
3 
of  soda,  injurious  effects  if  mixed  with 
sulphate  of  copper,  3 


Arseniuretted  hydrogen,  213,  487 
gas,  cases  of  poisoning  from,  7,  8 

occupations  involving  inhalation  of, 
7-14 
I.  aniline  colors,  manufacture  of; 
2.  ballooning  for  militant  pur- 
poses; 3.  bleaching  powder 
works;  4.  block  and  feathered 
tin;  5.  bronzing  art  metal; 
6.  bullion  refining;  7.  chem- 
ical workers:  (a)  manufac- 
ture of  bleaching  powder; 
[b)  manufacture  of  iron  sul- 
phate; (c)  manufacture  of 
soda  sulphate;  (d)  manu- 
facture of  zinc  chloride  and 
zinc  sulphate;  (e)  roasting 
and  extraction  of  mineral 
ores;  (/)  "store  plates" 
(dipping);  (g)  zinc  smelting; 
8.  galvanizers;  9.  paper  manu- 
facture and  works;  10.  physi- 
cists and  physiologists;  11. 
professional  chemists;  12. 
trade  processes, 
poisoning  from,  in  ballooning,  213 
professions  and  occupations  exposed 

to  risk  from,  7-12 
symptoms  from  inhalation  of,  8 
treatment  for  the  inhalation  of,  12 
Art  and  utility  ware,  mixing  of  glaze  and 

decorating,  no 
Arteriosclerosis,  245,  272,  277 
Artificial  flowers  {see  Arsenite  of  copper),  3 

manure,  682 
Artists,  703 

commercial,    lead    poisoning  '  among, 
102,  103 
Artists'  cramp,  289 

Ascaris  Lumbricoides,  causative  worm  and 
its  life  history,  183 
dangers  of  infection,  184 
frequency  among   and  importance   to 

laboring  classes,  184 
treatment,  184 
Ashmen,  717 
Asphalt  workers,  633 

Asphyxia,  from  carbon  dioxide  in  silos,  672 
Ataxia,  professional,  270 
.-\uricle  {see  Ear). 

cause  of  eczema  of,  340 
effect  of  blows  upon,  340 

of  exposure  to  extreme  cold,  339 


INDEX    OF    SUBJECTS 


895 


Auricle,  effect  of  exposure  to  extreme  heat, 

339 

major  injuries  of,  340 
Australia,  S.,  Compensation  Act,  817 
Automobilists,  716 
Aviation,  21 1-2 17 

accidents  of,  213 
Aviators,  accidents  to,  213 

hygiene  of^  216 

Babbitting,  lead  poisoning  from,  21 

Bacillus  anthracis,  158-161 

Baker  oil  region,  diseases  among  employees 

in,  139 
Bakers,  acute  endocarditis  among,  242 
anaemia  among,  238 
chronic  endocarditis  among,  243 
diseases  of,  687 
Ballistite,  manufacture  of,  557 
Ballooning,   poisoning   from   arseniuretted 
hydrogen  gas  in,  8 
military,  poisoning  from  arseniuretted 
hydrogen  gas  in,  213 
Balloons,  gas  poisoning  in,  213 

dirigible,  213 
Barbers,  700 

Basic  slag,  manufacture  of,  682 
Basophilic  granules,  97-99 
Baths,  443-463 

Batteries,  storage,  manufacture  of,  497,  528 
Beat,  elbow,  446 
hand,  446 
knee,  444 
Bed  and  bedding,  472 
Bedbugs,  430 

Beer,  contaminated  with  arsenic,  12,  13 
Bellite,  560 

Benzene  poisoning  {see  Benzol  poisoning), 
136 
causes  of  acute,  138 
effects   of   on   health  as  a  "drier" 

added  to  paints,  81 
poisoning  {see  Naphtha),  136 
rarity  of  chronic,  139 
skin  lesions  caused  by,  140 
t^nks,  description  of  an  accident  in,  138 
Benzol,  effects  of    on  health  as  a  "drier" 
added  to  paints,  81 
poisoning  {see  Naphtha  and  benzole), 

136 
preventive  measures,  143 
references,  143,  144 
workers  in,  543 


Bessemer  steel  works,  587 
Bichromate  works  in  Germany,  305 

in  Great  Britain,  regulations  in,  305 
in   Scotland,   effect  on    employees  of 
work  in,  302 
Binding  room  processes,  613 
Bird  skins,  cases  of  arsenic  poisoning  from 
sorting  of,  6 
tests  for  mine  air,  620 
Birmingham,    England,    health    of    brass 

workers  in,  27-34 
Bisque  making,  634 
Bisulphide  of  carbon  poisoning,  35-42 
Blacksmiths,  598 
anaemia  among,  238 

arteriosclerosis  among,  245 
chronic  endocarditis  among,  243 
primary  cardiac  overstrain  among,  240 
Blast  furnaces  {see  Carbon  monoxide  poison- 
ing), 586 
constant  changes  in  operation  of,  50 
gas,   occupations   involving    most   ex- 
posure to,  51 
I.  cleaning  cold  mains  and  work  done 
by  repair  men;  2.  oilers  and  sweep- 
ers. 
Bleaching  powder   works,   poisoning   from 
arseniuretted     hydrogen     among 
employees  in,  9,  10 
Block  and  feathered  tin  {see  Tin). 
Blood,  alterations  in  the  hemoglobin  of,  2^3 
in  acute  anaemia,  238 
circulatory   system    and  kidneys — By 
Thomas  S.  Lee,  diseases  of,  235- 
248 
in  chronic  secondary  anaemia,  239 
pressure  in  arteriosclerosis,  245 

in  chronic  interstitial  nephritis,  248 
secondary  low,  247 
Blow    pipes,  use  of  by  braziers  and  hard 

solder  workers,  23 
Blue  line  on  the  gums  as  a  sign  of    lead 

poisoning,  85 
Boards  of  Administration,  869 
Body,  abnormal  position  of,  443 

dress,  465 
Boilermakers,  598 
Bombs,  manufacture  of,  562 
Bone  yards,  679 
Boots  and  shoes,  industry,  657 
Bottling  establishments,  695 
Bowels,  care  of,  468 
Boxwood,  African,  675 


896 


INDEX    OF    SUBJECTS 


Bradycardia,  241 
Brain  work,  471 

Brass,   fine  or  red;   cheap    and  yellow,  22 
casters— By  T.  M.  Legge,  physical 
examination  of,  for  Factory  De- 
partment of  the  Home  Office,  27 
and  poUshers,   evidences   of    lead 
poisoning  in,  28 
occupations    involving    inhalation    of 
metallic  fumes  include,  27-34 
I.  chandelier  fitting  and  polishing;  2. 
electric  welding  and  work  requir- 
ing the  use  of  modern  blow  pipes; 
3.   gun   metal   work;   4.    those   in 
which  zinc,  lead,  iron,  copper  and 
cadmium  oxide  are  used;  5.  work 
of  braziers  and  hard  solder  workers. 
Brass  casting,  new  method  of  pouring  in,  30 
regulations   made  by  the  Secretary  of 
State,  Great  Britain,  1908,  32,  2;^ 
Btass  chills  {see  Zinc  ague),  19 

copper  and  zinc  poisoning,  15-27 
dust,  analyses  of,  reveals  lead,  28 
does  not   produce   "brass  founders' 

ague,"  22 
founders'  ague  (see  Zinc),  19,  481 
causation  of,  31 

in  brass  casters  in  Birmingham,  Eng- 
land, 27,  28 
industry,  492,  495,  498 
legislation  on,  808 
poisons  in,  492 
poisoning — By  E.  R.  Hayhurst,  15-26 
cf.  brass  founders'  ague,  23 
chronic  effects  of,  23 
references,  25,  26 
remedial  measures,  24 
pseudo-brass  poisoning,  22 
polishers — By  T.  M.  Legge, 
diseases  of,  491 
health  of,  27-34 

undue  incidence  of  phthisis  among,  2  8 
Braziers  (see  Charcoal  braziers),  43 

pseudo-brass  poisoning,  22 
Breweries,  694 
Brewers,  694 

acute  endocarditis  among,  242 
and    bottling    works,    injuries    to    the 
eye  arising  out  of,  311 
Brickmakers,  628 
Brickmasons,  634 
Brick  yards,  628 
Bright's  disease,  277 


Bromine  compounds,  539 
Bronze  founders  (cf.  Copper  founders),  15 
Bronzing  of  art  metal,  poisoning  from  arseni- 
uretted      hydrogen      gas     among 
workers  engaged  in,  7 
in  lithography,  614 
powder,  493,  497 
Broom  makers,  575,  576 
Brush  makers,  575 

Building  trades,  injuries  to  the  eye  in,  308 
Bulgaria,  legislation,  818 
Bullion    refining,    poisoning    from    arseni- 
uretted     hydrogen     gas     among 
workers  in,  7 
Burtonian  line  {see  Blue  line  on  the  gums), 

85 
Butchers,  arteriosclerosis  among,  245 

diseases  of,  690 
Buttons,  manufacture  of,  643 
Bysinosis,  438 

Cabinet  makers,  676 

injuries  to  the  eye  of,  308 
Caisson  disease  {see  Compressed  air  illness), 

185-187 
Calcium  cyanide,  541 

nitrate,  manufacture  of,  541 
California,  notification  law,  825 
Cancer,  age  of,  381 
definition  of,  380 

effect  of  special  occupations  upon,  389 
I.  cobalt  miners;  2.  manufacturers  of 
coal  tar  products 
habits  which  tend  to  bring  on,  388 
heredity  of,  383 
hyperplasia  of,  383 
incidence  of,  380 
in  different  occupations,  390 
injuries  and  chronic  inflammation  as  a 

basis  for,  386 
medico-legal  aspect  of, 

I .  dangers  in  use  of  X-ray,  389 
metaplasia  of,  383 

occurrence  of,  in  persons  employed  in 
"sheep-dip"    factories    {see   Sheep 
dip),  5 
occurrence  of,  in  those  who 

have  taken  arsenic  {see  Arsenic),  5 
question  of  contagion  of,  382 
of  house  infection  of,  382    . 
references,  389,  390 
summary  of,  388 
theories  of,  381 


INDEX   OF   SUBJECTS 


897 


Cancer  and  Occupation — By  E.  E.  Tyzzer, 

380-390 

Cancer  and  Occupation  —  X-ray.  Radium 
— By  E.  E.  Tyzzer  and  Thomas 
Ordway,  380 

Cane  workers,  676 

Canned  food  and  fruit  as  sources  of  plumb- 
ism,  82 

Canneries,  693 

Caoutchouc,  505 

Carbonated  waters,  manufacture  of,  695 

Carbonate  of  lead  {see  White  lead),  79-82 

Carbon  bisulphide,  540,  811 

acute  poisoning  by,  reported  in  Ohio,  38 
occupations  in  which  workers  are  most 
liable  to  poisoning,  35,  36 
I.  extraction  of  oil  and  grease;  2.  in 
its  own  manufacture  and  various 
other  uses  mentioned;  3.  rubber 
industry:  (a)  cement  making;  (b) 
"cold  curing"  of  drug  sundries;  (c) 
filling  cement  tubes  and  cans;  (e) 
splicing   ends   of  inner   tubes  for 
tires;  (0  vulcanizing  and  dissolv- 
ing rubber;  (g)  water-proofing  and 
spreading    rubber   on    fabrics;  4. 
various  uses  of  cements  dissolved 
in  CSj. 
pathology,  37,  38 
pharmacology  and  animal  experiments, 

37 

predisposing  factors,  37,  38 

symptomatology,  38;  39 

uses,  35 

I.  cleansing  establishments  for  re- 
moval of  grease  spots;  2.  degreas- 
ing  vegetable  and  animal  matter; 
3.  destruction  of  insect  pests,  ro- 
dents, etc.;  4.  dissolving  out  tar 
from  industrial  products;  5,  ex- 
traction of  sulphur  from  ores;  6. 
making  Greek  fire;  7.  preparation 
of  cellulose  for  artificial  silk;  8. 
preparation  of  solutions  of  wax 
for  coating  plaster  Casts;  9.  prep- 
aration of  various  chemical  prod- 
ucts; 10.  preparation  of  waxed 
paper. 
Carbon  bisulphide  poisoning — By  E.  R. 
Hayhurst,  35-42 

diagnosis  of,  39,  40 

bisulphide     poisoning,     acute,    differ- 
ential   diagnosis    from    i.    acute 
57 


alcoholism;  2.  anilin;  3.  benzine; 

4.  benzol;  5.  carbon  monoxide;  6. 
carbon  tetrachloride;  7.  hydrogen 
sulphide;  8.  sulphur  monochloride. 

chronic  differential  diagnosis  from,  40 
I.  chronic  alcoholism;  2.  chronic  gas 
poisoning;    3.    hysteria;    4.    lead; 

5.  locomotor  ataxia;  6.  mercurial- 
ism;  7.  neurasthenia;  8.  paresis; 
9.   progressive  muscular  atrophy. 

references,  41-42 
dioxide  poisoning,  672-725 
in  silos,  672 

monoxide,  acute  poisoning  from,  47-69 
chemistry,  44,  45 
chronic  poisoning  from,  69-73 
coma,  60-65 

in  carburetted  water  gas,  40 
method  of  determining  quantitative 

and  qualitative  analyses,  70 
psychoses  {see  Burry,  Sibelius,  Steir- 
lin,  Zaugger,  Giese,  Mott,   Libin, 
Weidner,    O'Malley,    and    Abra- 
hamson,  64). 
toxicology,  45,  47 
gas,  accidental  poisoning  from,  44 
effects  of  in  alcoholism,  43 

in  syphilis,  43 
poisoning,  43-74 
acute,  59 

prodromata,  59-60 
symptomatology  of,  59-63 
analysis  of  the  blood  in,  61 
clinical  pathology  of  chronic,  70-72 
from  using  ovens,  54 
in  balloonists,  213 
medico-legal  question,  57-59 
occupations  involving  danger  from, 
48-49 
I.  carbon  monoxide  is  used  in  pre- 
serving fruit  and  vegetables;  2. 
from  fumes  of  gasoline  engines; 
3.  gassing   occurs  with  moder- 
ately ill  effects;  4.  heating  and 
steam-power  plants;   5.   indus- 
tries using  ovens;  6.  manufac- 
ture of  steel;  7.  manufacture  of 
illuminating     gas;     8.     use     of 
power  or  producer  gas. 
post-mortem    pathology,    in    acute 

poisoning,  sequelloe  of,  63-66 
spectroscopic  examination   and 
chemical  tests  in,  61-63 


898 


INDEX    OF    SUBJECTS 


Carbon     poisoning,     symptomatology     of 
chronic,  72,  73 
treatment  of,  66-69 

tetrachloride,  540 
Carbonizing,  666 
Carboxyhemoglobinemia,  236 
Carburetted  water  gas  containing  carbon 

monoxide,  43 
Carcass,  manufacture  of,  562 
Cardboard  workers,  668 
Cardiac  hygiene,  244 

overstrain,  primary,  239 
Carpenters,  676 

acute  endocarditis  among,  242 
Carpet  cleaning  establishments,  549 
Carpets,  manufacture  of,  653 
Carriage  painting  {see  Painters'  trade),  116 
Casting  of  brass,  492 

of  iron  and  steel,  595 
Castings,  brass,  cleaning  of,  494 

iron,  cleaning  of,  596 
Casual  labor,  456 

Cataract,  glass-workers'  average  age  of  in- 
capacity from,  335 

character  of,  338 

examination  and  removal  of,  336 

explanation  of  origin  of,  332 

glass  furnace  workers',  638 
Celluloid  industry,  645 
Cellulose,  use  of  carbon  bisulphide  in  prep- 
aration of,  36 
Cement,  dissolved  in  carbon  bisulphide,  36 
workers  in,  633 

tube  and  can-fillers,   exposure    of    to 
carbon  bisulphide,  36 
Cerebral  plumbism  (see  Lead  poisoning),  87 
Cerussite,  77 
Cestodes,  184,  185 

description  of  worms  and  their  life  his- 
tory, 185 

influence  on  host,  185 

prophylaxis,  185 

tenia  saginata,  184 
solium,  184 

tenifuges,  185 
Chair  factories,  676 
Chalicosis,  438 
Chamber   process,    manufacture    of    white 

lead,  80 
Chandelier  fitters  and  polishers,  develop- 
ment of  lead  poisoning  among,  28 

makers,  496 
Change  of  work,  456 


Charbon  {see  Anthrax),  158 

bacteridien,  158 
Charcoal    braziers,    accidental    "gassing" 

and  suicides  among,  43,  44 
Chauffers,  716 

affected  by  exhaust  gas  {see  Gas),  56 
Chemical  cleaning  works,  549 

products,  use  of  carbon  bisulphide  in 

preparation  of,  36 
workers,  535 

hazards  in  the  coal-tar  color  indus- 
try, 545 
morbidity  of,  536 
works,  cases  of  arsenic  poisoning  in, 
6-8 
phosphorus  poisoning  in,  145 
poisoning  from  arsem'uretted  hydro- 
gen gas  among  workers  in,  7 
Chest,  effect  of  dust  upon,  297 
Child  birth,  protection,  843 
labor,  449 
law,  852 
Chili  nitre,  683 

China,  lead  poisoning  in  the  trades,  82 
Chinon,  546 
Chloride  of  nitrogen,  540 

of  sodium,  696 
Chlorine  industry,  539 
Chloroform,  540 
Chorea,  local,  270 
Chromates,  legislation  on,  811 
Chrome  poisoning,  541 

ulcers,  541 
Chromium  compounds,  540 
Chromo-lithography,  614 
Chronic    mercurial     poisoning,     principal 
symptoms  of,  131 
phosphorus  poisoning — By   Dr.   Alice 

Hamilton,  145-152 
X-ray  dermatitis  and  cancer,  cause  of, 

392 
Cigar  makers,  696 

cramp  of,  289 
Clay  lungs,  628 

product  workers,  628 
Clergymen,  702 
CUnic,  Milan,  function  of,  765 
Clocks,  manufacture  of,  583 
Clothing,  cause  of  disease,  464 

fire-proof,  464 

for  workshops,  442 

waterproof,  464 
Coal  gas  {see  Illuminating  gas). 


INDEX    OF    SUBJECTS 


899 


Coal  gas,  composition  of,  53 
men,  717 

miners'  phthisis,  21S 
Coal  lar  color  industry,  544 

distillation,  products  of,  136 
dyes,  phosphorus  poisoning  in  the 

extraction  of,  153 
products,  542 
Cocobola  wood,  674 

Coke,  smelting  of,  in  the  blast  furnace,  49 
"  Cold  curing"  of  drug  sundries  {see  Carbon 
bisulphide),  uses  of,  37 
storage  plants,  695 
Colic  and  constipation,  as  early  symptoms 

of  lead  poisoning,  86 
Colica  pictonum  {see  Lead  poisoning),  75 
Collodion  cotton,  manufacture  of,  556 
Combs,  manufacture  of,  645 
Commercial  artists,  lead  poisoning  among, 
102,  103 
employees,  708 
Commission    on    occupational    diseases    in 

Illinois,  102 
Commissions  legislative,  855 
Compensation  act,  Australia,  817 
JBulgaria,  818 
France,  817 
Germany,  817 
Great  Britain,  815 
Methods  of,  814 
Ontario,  817 
S\^'itzerland,  818 
Compressed  air,  809 

illness — By  Seward  Erdman,  187-210 
active  treatment  of,  208 
affection  of  the    bones,   joints  and 
periosteum  in,  198 
of  the  internal  organs  in,  198 
of  the  nervous  system  in,  196 
of  respiratory  system  in,  198 
of  the  sexual  apparatus  in,  198 
of  special  senses  in,  197 
of  vascular  system  in,  198 
atmospheric  conditions  and,  193 
carbon    dioxide,    carbon    monoxide 

and, 193 
chief    symptoms    in    order    of    fre- 
quency, 196 
chronic  symptoms  in,  199 
degree  of  exposure  in  re  to,  190 
diagnosis  of,  201 

etiology  of,  and  predisposing  factors, 
190-193 


Compressed  air  illness,  exciting  cause  of,  193 
frequency  of,  188,  189 
gastrointestinal  symptoms  in,  198 
immunity  from,  193 
length  of  exposure  in  re  to,  191,  192 
of  exposure  at  different  pressures 
in  caisson  and  tunnel  work,  202, 
203 
localized  collections  of  gas  in,  198 
method  and  duration  of  decompres- 
sion in  re,  203-208 
mortality  in,  200,  201 
nature  of,  189,  190 
noxious  gases  and,  193 
and  organic  diseases,  192 
pathology  of,  193-195 
personal  equation  in  connection  with, 

192 
phenomena  of  compression,  195 

of   decompression,    196 
prognosis  of,  201 

prophylactic  treatment  of,   201-208 
references,  210 

skin  and  subcutaneous  tissues  in,  198 
symptoms  of,  196-201 
theories  on,  190 
treatment  of,  201-210 
uniform   decompression   in  re,    203, 
204 
Confectioners,  687 

Connecticut,  notification  of  diseases  in,  825 
Constitutional  eye  disease,  traumatism  as 

an  exciting  cause  of,  314 
Construction  camps,  454 
Contagious  diseases,  glass  blowers,  813 
Control  of  occupational  diseases  by  notifi- 
cation, 821 
Cooking,  460 
Cooks,  700 
Coopers,  677 
Copodj'skinesia,-  270 
Copper  colic,  15 

electrolytic  refining  of,  16 

founders,  lack  of  evidence  of  poisoning 

among,  16 
poisoning  from  arseniuretted  hydrogen 
gas  in  process  for  the  recovery  of, 
12 
significance   as   an   industrial   poison, 

IS.  16 
smelting  of,  and  cases  of  arsenic  poison- 
ing, 6 
Copperman's  chest,  15 


900 


INDEX    OF    SUBJECTS 


Copper  miners,  498 

poisoning— By  Hayhurst,  15,  16 

lack  of   evidence  of,  among   bronze 
or  copper  workers,  16 
Copper  poisoning,  24,  25 

salts,  contact  poisoning  caused  by,  16 

smelters,  499 

smelting,  obnoxiousness  of  sulphuric  and 

other  fumes  in,  16 
smiths,  499,  500 

uniformly  healthy,  16 
zinc  and  brass  poisoning  references,  24-- 
26 
Cordage,  manufacture  of,  654 
Cordite,  manufacture  of,  559 

habit,  560 
Coremakers,  in  brass  foundries,  491 

in  iron  foundries,  595 
Corrosive  sublimate,  poisoning  by,  127 
Corundum  wheels,  manufacture  of,  635 
Cotton  and  jute  workers,  anaemia  among, 

239 
Cotton  mills,  artificial  moisture  in,  651 

carding  in,  650 

card  stripping,  651 

employees,  diseases  of,  649 

excessive  heat  and  humidity,  649 

defective  light  in,  647 

dust  in,  649 

spinning  department,  648-650 

weaving  department,  648 
spinners,    acute    endocarditis    among, 
242 
Courbatures  {see  Compressed-air  illness). 
Cow  pox,  425 
Craft  neuroses   (sec  Occupation  neuroses), 

270 
Cubic  air  space  required,  431 
Curled  hair  factories,  576 
Cutlers,  mortality  of,  600 
Cutlery  industry,  599 
Cyanmethemoglobinemia,  237 
Cyanogen  chloride,  540 
Cysticerci,  429 

Dancing,  470 

Danube     bridge    (see    Compressed-air    ill- 
ness), 188 

Dairy  workers,  692 

De-arsenicated  acid  {see  Tin). 

value  of,  in  preventing  poisoning  from 
arseniurctted  hydrogen  gas  in 
block  tin  works,  12 


Death  certificates,  statement  of  occupation 
in,  828 

rates,  restricted,  798 
specific,  798 
Decompression  {see  Compressed-air  illness). 

exciting  cause  of,  193 
Deformities,  postural,  443 
Dementia  precox,  272 
De-silvering  of  lead,  78 
Diagnosis,  early,  in  occupational  diseases, 

{see  Lead  poisoning),  96 
Diamond  cutters,  636-637 

polishers,  636 

setters,  636-637 
Diet,  in  arteriosclerosis,  246 

in  chronic  interstitial  nephritis,  248 
Diethylaniline,  545 
Dimethylaniline,  545 

Diminished    atmosphere — By    George    M. 
Kober,  effects  of,  on  health,  211- 

217 
Dinitrobenzol,  544 
Dinitrophenol,  545 

"Dippers"  {see  Potterj-  industry),  109 
Dirigible  balloons,  213 
Disability,  occupational  in  U.  S.  Navy,  719 
Diseased  and  abnormal  eyes,  disposition  of, 

314 
Diseases  of  the  eye,  excessive  exposure  to 
light  and  heat  due  to,  326 

toxicology  of,  326 
Distilleries,  694 

Divers,  occupational  diseases  among,  187 
Divers'  palsy  {see  Compressed-air  illness). 
Domestic  servants,  700 
Draymen,  717 
Dressing  rooms,  443 
Drinking  water,  443 

safety  limit  of  lead  in,  91 
Drummers'  paralysis,  703 
Dry  cleaning  with  benzine,  etc.,  549 
Dryers  for  paints,  manufacture  of,  551 
Dupuytren's  contracture,  281 
Dust,  770 

amount  of,  in  different  establishments, 

439 
collection  and  removal  of,  441 
definition  of  industrial,  778 
diffusion,  prevention  of,  441 
entrance  into  the  lungs  of,  230-232 
filters  for,  441 

formation,  prevention  of,  440 
and  fumes,  438 


INDEX    OF    SUBJECTS 


901 


Dust,  injurious,  persons  engaged  in  U.  S.,  777 

miscellaneous,  808 

precipitation  by  electricitj',  441 

rag,  811 

settling  chambers  for,  441 

stone,  811 

textile,  810 

tuberculosis,  427 

trades  affected  by,  778 
Dusty  occupations,  general  conclusions,  786 
Dutch  process  of  manufacture  of  white  lead, 

79 
Dye  works,  655 

Dynamite,  manufacture  of,  558 
Dyskinesia,  270 

Ear  affections,  middle,  causes  of,  297 
care  of,  466 

causes  of  impairment  of  hearing  of  tele- 
phone operator,  349 
continued    exposure    to    loud    sounds 

injurious  to,  339 
drum  head,  cause  of  rupture  of,  343 
effect  of  sound  waves  on,  346-347 

I.  experiment  with  pigeon, 
external  canal,  causes  of  stoppage  of,  341 
I.  accumulation  of  dust;  2.  cutting 

hair, 
causes  of  wounds  of,  341 
mycosis  of,  341 
membrane  vibrans,  causes   of   rupture 

of,  342 
occupational  injuries  to,  340,  341,  344- 

345 
I.  blacksmith;  2.  chemical  industries; 
3.   metal   workers;   4.   mining;    5. 
stone  masons;  6.  wood  workers, 
occupational  injuries  and  diseases  of^ — 
By  Clarence  John  Blake,  339-350 
Earthenware,  glazing  and  decorating,  108, 
109 
lead  poisoning  in  the  trades,  82 
manufacture  of,  629 
East    rover    tunnels    {see    Compressed-air 

illness). 
Eating  houses,  460 

Eczematous   eruptions,   paraffin   and   ben- 
zine workers  develop,    139,  140 
Effects    of    diminished    atmosphere    upon 
health — By    George    M.    Kober, 
211-217 
preventive  measures,  216 
references,  216-217 


Eider  bridge  (cf.  compressed-air  illness),  188 
Elbe  tunnel,  method  of  decompression  tried 

at,  207 
Electrical  apparatus,  manufacture,  497 
injuries,  587 

pathology  of,  409 
Electrical  injuries  and  electrical  shock — By 
Sir  Thomas  Oliver,  402-414 
references,  412 
ophthalmia,  587 
causes  of,  412 
shock,   persons  restored  to  life  by  ar- 
tificial    restoration     after     being 
apparently  killed  by,  404 
theories  of,  403 
treatment  of,  408,  409 
Electrical  welding,  587 

workers  suffer  from  metal  chills,  23 
Electric  current,  direction  of,  407 

effect    of    entrance    to    the    body   of, 
404-406 
I.  burning, 
medical  view  point  of,  406 
Electric  shock,  causes  of  death  in,  407,  408 
I.  experiments  with  dogs, 
resuscitation  from,  413,  414 
I.  instructions. 

(a)  immediately   break   circuit; 

(b)  instantly   attend  to    victim's 
breathing. 

Electrodes,  manufacture  of,  528 

Electroplating,  581 

Electro  typing,  612 

Elevator  employees,  711 

Emerald  green,  cases  of  arsenic  poisoning  in 
manufacture  of,  6 
dried  precipitate  an  irritant  dust,  3 

Emerald  green  industry,  danger  of,  6 

Emery  paper  and  wheels,  manufacture  of, 
635,  636 

Employees,  responsibilities  of,  460 

Employment  of  women,  regulated,  835 

Encephalitis,  case  of,  reported  by  Potts, 
due  to  gasoline  poisoning,  138 

Endocarditis,  acute,  242 
chronic,  243 

Engineers  and  firemen,  stationary,  708 
locomotive,  712 

Engravers,  615 

Environments,  injurious,  430 

Epidemic  arsenical  poisoning  from  con- 
sumption of  beer  and  other  arti- 
cles, 12,  13 


902 


INDEX    OF    SUBJECTS 


Erethism  (see  Chronic  mercurial  poisoning), 

131 
Erethismus  mercuralis,  128 
Ethane,  620 

tetrachloride  of,  570 
European  Labor  Laws,  804  et  seq. 
Exercise,  effects  of,  468 
Exhibits,    on    occupational    diseases    and 

hygiene,  14 
Explosives,  accidents  from,  564 
gaseous  products,  566 
hazards  in  certain  industries,  567 
high,  choice  of,  561 
manufacture  and  use  of,  554 
permissible  or  safety,  561- 
Eye,  accidental  injuries  of,  307-325 
care  of,  467 
diseases,  bacteriology,  313 

estimation  of  economic  damage  of, 

328 
formula  of  magnus  of,  329 
resume  of,  330 

systemic  poisoning   causing  loss   of 
sight,  326 
etiology  of  industrial  injuries  of,  308 
glass-workers'  cataract  of — By  T.  M. 

Legge,  331-338 
injuries,  cosmetic  relations  of,  308 
instruments  used  in,  321 

I.  diaphanoscopy;   2.  ophthalmo- 
scope; 3.  siderscope;  4.  X-ray. 
mechanism  of  special  types  of,  314 
objects  causing,  312 
prophylaxis  of,  315-317 

I.  agricultural  worker;  2.  "chip- 
per;"   3.    factory    worker;     4. 
grinders, 
objective  examination  of,  319 
occupational  injuries  and  diseases  of — 

By  H.  V.  Wurdemann,  307-330 
poisoning  of,  326,  327 

I.  aniline;  2.amyl  alcohol;  3.  arsenic; 
4.   bisulphide;   5.  lead  poisoning; 
6.  methyl  alcohol;  7.  tea  tasters, 
protective  legislation  on,  317 
relation  between  accidental  and  pre- 
viously   intercurrent    and     post- 
traumatic   changes    in    the    eye, 
322 
responsibility   of   the   physician   in, 
322 
strain,  occupations  incurring  and  dis- 
eases due  to,  325 


Factories,  origin  of,  9 
Fallacies  of  statistics,  789 

classification,  792 

death  rates,  795 

index,  794 

influenced  by  infant  mortality,  765 

misuse  of  averages,  793 

ratios,  793 

tabulation,  792 

variations,  794 
Farmers  and  farm  laborers,  670 
Fatigue,  chemical  changes  in,  252 

and  accidents,  265,  266 

borderland  of  illness,  259 

disease,  255-257 

disease,  270 

effects  of  in  relation  to  carbon  monox- 
ide poisoning,  43 

in  the  human  body,  253 

of  tissues,  250-252 

prevention  of,  448 

recovery  from,  253,  254 

tests  for,  254,  255 

health  of  industrial  workers,  258 

industrial  output,  257 

occupation — By  Frederic  S.  Lee,  249- 

269 
-  references,  268,  269 

scientific  management,  267,  268 
Fats,  474 

Feather  workers,  577 
Febbre  carbonchiosa  (see  Anthrax),  158 
Feet,  care  of,  467 

flat,  445 
Felt  hat,  manufacture  of,  531 
Female  labor,  449 

effects  upon  health,  450,  451 
Ferrosilicon,  487 

phosphorus  poisoning  through  exposure 
to  fumes  from,  145 
Fertilizers,  manufacture  of,  645 
Fettling  (see  Glazing  of  tiles),  iii,  630 
Fiberloid,  manufacture  of,  645 
Fi^bre  charbonneuse  (see  Anthrax),  158 
Filariasis,  181— 183 

definition,  181 

elephantiasis,  histo-pathology,  clinical 
forms,  1 81-183 

endemic  lymphangitis,  182 

lymphatic  tumors,  182 

lymphatic  varicocele,   filarial  orchitis, 
lymph  scrotum,  182 

mode  of  infection,  181,  182 


INDEX    OF    SUBJECTS 


903 


Filiarisis,  parasite  stage  of  filaria  iu  man 
and  mosquito,  18 r,  182 

theories  of  pathogenesis,  182 

treatment  of  filarial  lymphangitis  and 
lymphatic  tumors  of  elephantiasis, 
183 
File  cutting,  602 

dangers  in,  82 
Filite,  manufacture  of,  557 
Finger  nails,  care  of,  467 
Finland,  law  prohibiting  the  use  of  white 
phosphorus  in  match  factories  in, 
157 
Fire  arms,  manufacture  of,  602 

clay  industry,  629 

damp,  620 

gilding,  527 

hazards,  in  manufacturing  plants,  567 
Firemen,  707 

and    boiler    operators,    carbon    mon- 
oxide poisoning  among,  54 
Fireworks,  exposure  to  fumes  of  phosphorus 
in  the  making  of,  145 

manufacture  of,  564 
First  aid  outfit,  423 
Fishermen,  707 
Fish  industry,  689 
Flat  feet,  445 
Flax  workers,  653 
Flaying  yards,  679 
Fleas  and  flies,  430 
Flexibilitas  cerea,  279 
Flour  mill,  explosions,  686 

workers,  685 
Flowers,  artificial  (see  Artificial). 
"Folie  du  cuir"  (see  Leather-workers'  insan- 
ity). 
Food,  473 

amount  required,  474 

and  cooking,  460 

arsenic  in,  12,  13 

cost  of,  475 
Foot  and  mouth  disease,  424 
Foot  wear,  465 
Forgemen,  598 

Fougasses,  manufacture  of   562 
Foundries,  brass  and  iron,  491,  595 
Foundry  workers,  491,  595,  597 
"Fragilitas    ossium"   reported    by  several 

French  writers,  151 
France,  compensation  act,  817 

phosphorus     necrosis     among     match 
makers  in,  155 


Fulminating  powder,  555 

Fumes  diffusion,  prevention  of,  440 

Function  of  clinics,  765 

Furnace  workers'  cataract,  638 

Furniture  repair  shops,  677 

Furriers,  576 

Fuses,  manufacture  of,  563 

Galena,  77 

Galvanizing  {see  Zinc),  502 
uses  of,  17 

works,  poisoning    from    arseniuretted 
hydrogen     gas     among     workers 
in,  7-1 I 
Ganister  disease,  222 
Gardeners,  670 
Garment  workers,  660 
Gas,  blast  furnace,  in  the  steel  industry,  49 
carburetted  water  gas  for  illuminating 

purposes,  43 
cleaning  (sec  Carbon  monoxide  poison- 
ing), 
exhaust,  from  gasoline  engines,  55,  56 
illuminating    (c/.     Carburetted   water 

gas),  43 
new  method  of,  to  prevent  gas  poison- 
ing, 50 
occupations    involving     exposure     to 
producer  or  power,  i.  glass  makers; 
2.    heating    linotype    kettles;    3. 
heating  monotype  kettles;  4.  lac- 
quering stoves,  etc.;  5.  metallurg- 
ical plants;  6.  use  of  the  iron  in 
tailoring  establishments, 
producer  or  power,  poisonings  or  gass- 
ings from,  54 
(see  Carbon  monoxide),  43 
Gaseous  projectiles,  562 
Gases,  table  of  statistics  of  carbon  monoxide 

and  other,  47 
Gas  fitters,  515 

Gasoline  engines,  carbon  monoxide  poison- 
ings from  the  exhaust  of,  55 
Gasoline  poisoning,  fatal  cases  of,  139 
Gassing  (see  Carbon  monoxide  poisoning), 
description  of  process  of  manufacture 

of  gas  which  gives  rise  to,  53 
in  cities  using  water  gas,  53 
in  construction  of  gas  and  water  mains 

and  in  repairing  of  leakages,  53 
mild  forms  of,  55 

sequelae  or  subsequent  effects  of  car- 
bon mono.xide,  43-46 


904 


INDEX    OF    SUBJECTS 


Gassing   table  showing  incidence  of,  in  the 
Illinois  investigation,  and  also  the 
gas  route,  52 
where     liable     to     occur     {see     Steel 

industry),  50-53 
workers  exposed  to,  from  defective  gas 
mains,  53 
Gastro-intestinal    tract,    irritant  action    of 

salts  of  arsenic  on,  5 
Gelatine,  manufacture  of,  682 
Genu  valgum,  444,  498 
German  silver,  fumes  arising  from  pots  of, 
16 
manufacture  of,  17 
Germany,  compensation  acts,  817 
Gilds,  manufacture  of,  498 
Gingiv'itis  {cf.  Mercurial  stomatitis),  127 
Glanders  and  farcy,  424 
Glass-blowers,  cataract  of.  638 

contagious  diseases  among,  813 
emphysema,  639 
syphilis  among,  337 
I.  cause;  2.  prevention, 
blowing,  injuries  to  the  eye  in,  308 
cutters,  diseases  of,  639 
pearl  industry,  580 
polishing,  639 

workers'    cataract,     bottle      finishers' 
danger  of,  332 
causes  of,  332 

glasses  prepared  to  prevent  incapac- 
ity arising  from,  337 
question  as  to  whether  heat  or  light 

rays  cause  of,  336 
references,  338 

table  comparing  nature  of  changes  in 
crystalline    lens   of   glass-workers 
and  other  people,  334 
workmens'  compensation  act  applied 
to,  33^ 
Glaze  mixing  and  dipping,  630 
Glazing  and  decorating,  tiles,  no 

white  ware,  108 
Gloves,  leather,  manufacture  of,  575 
Glucose,  manufacture  of,  68S 
Glue,  manufacture  of,  681 
Gob  fires,  620 

Gold,  extraction  of,  526,  580 
mining,  580 
smiths,  581 
Gout,  277 

(}rain,  elevator  workers,  684 
threshing,  684 


Granite  cutters'  cramp,  288 
Grease  spots,  removal  of,  by  carbon  bisul- 
phide in  cleansing  establishments, 

Great  Britain  compensation  act,  815 
Greek  fire,  manufacture  of,  562 

use  of  carbon  bisulphide  in  making,  36 
Grenades,  hand,  manufacture  of,  562 
Grinders,  steel,  599,  600 

injuries  to  the  eye  of,  308,  309 
Guano  works,  683 
Gun  cotton,  manufacture  of,  556 
Gun  metal,  brass  founders'  ague  in  casters 

of,  28 
Gunpowder,  manufacture  of,  554 
Gunsmiths,  602 

Habitual  mercurialism  (see  Mercurialism), 

126 
Hackmen,  717 
Hair,  care  of,  467 
dressers,  700 

pins,  manufacture  of,  645 
Hammermans'  cramp,  287 

paralysis,  598 
Hands,  care  of,  467 

effect  of  bichromate  solutions  on,  304 
I',    cause;    2.    remedy    (preparation 
recommended). 
Hardening   steel   magnets,   lead   poisoning 

from,  104 
Harvest  bug,  430 
Hatters  fur,  workers,  529 
Hazards,  physicians  knowledge,  important, 

824 
Headache,   when  present  in  plumbism   is 

usually  severe,  87 
Head  dress,  465 
Health  Boards,  815 

of  brass   workers — -By   T.    M.   Legge, 

27-34 
insurances,  818 
references,  34 
Heart,  dilation  of,  240 

functional  affections  of,  240 
insufficiency  of,  in  arteriosclerosis,  246 

in  chronic  endocarditis,  243 
overstrain  of,  239 
palpitation  of,  240 
Heat,  excessive,  effects  of,  435 
exhaustion,  435 
stroke,  435 
Hectograph  ink,  616 


INDEX    OF    SUBJECTS 


905 


Hemoglobinemia,  235 
Hemolysis,  235 

blood  in,  239 
Hernia,  446 
Hide  industty,  571 

Hides  {see  Arsenic)  preserved  with  arsenic,  4 
Historical  review  of  industrial  hygiene,  9 
Hook-worm  disease,  in  miners,  624 

in  planters,  671 
Horn  industry,  645 
Horse-hair  cloth  factories,  576 
Hotel  keepers  and  employees,  699 
Hours  for  labor,  449 
House  and  home,  461 
Housemaids'  knee,  444,  676 
House  painters,  statistics  of  lead  poisoning 
among,  81 

painting  {see  Painters  trade),  116 
Houses,  insanitary,  459 

for  wage  earners,  458 
Humidity,  434 

Hydrochloric  acid,  manufacture  of,  537 
Hydrofluoric  acid,  manufacture  of,  540     ' 
Hydrogen,  carburetted,  620 

sulphuretted,  620 
Hygiene,  industrial  progress  in  the  United 
States,  12 

of  workmen,  461 
Hypertension,   arterial,   in  arteriosclerosis, 

245 
in  chronic  nephritis,  248 

Ice,  artificial,  manufacture  of,  695 
Ice  men,  717 

Illinois  Commission  on  Occupational  Dis- 
eases, 863 
Health  Boards,  858 
notification  of  occupational  disease  in, 

825 
report  of,  102-116 
Illuminating  gas,  composition  of  water  and 
coal  gas,  5s 
industry,  manufactrue  of  and   carbon 
monoxide  poisoning  from,  52 
Illumination,  437 

Incandescent  lamps,  manufacture  of,  497 
Indian  rosewood,  675 
Indoor  occupations,  430 
Industrial   arsenic   poisoning    {see   Arsenic 
poisoning),  3 
betterment,  457 

diseases,  notification  of,  820,  457 
reporting  cases  of,  820 


Industrial  dusts,  definition  of,  778 
infectious  diseases,  423 
insurance,  454 

lead  poisoning,  fewer  victims  of  than 
formerly,  80 
prevalence   of    the    use    of    lead   in 
industries,  76 
mercurialism,   cardinal   symptoms  of, 

130 
phthisis,  785 
phosphorus  poisoning — By   Dr.    Alice 

Hamilton,  145-152 
plumbism,  cases  of,  in  New  York  State, 

102 
preventive  measures,  156-157 
poisoning,  acute,  418 
chronic,  418 
prevalence  of,  419 
poisons,  alphabetical  list  of,  720-739 
definition  of,  418 
protective  measures  against,  421 
selective  afl&nity  of,  418 
Industries  and  processes,  in  which  poison- 
ing may  occur,  740-748 
Industry,  characteristics  of  modern,  259 
Infant  mortality,  not  an  index,  797 
Infectious  occupational  diseases,  423 
Injuries  to  the  eye,  diagnosis  of,  318 

precaution  and  other  attention  to,  324 
prognosis  of,  323 

technical  treatment  of  {see  Text-books 
on  Ocular  therapeutics),  325 
In-knee,  444 
Insect    pests,    destruction    of,    by    carbon 

bisulphide,  36 
Institute   of  Tropical   Medicine   of  Porto 
Rico,  investigation  as  to  the  pre- 
valence   of    the   Ascaris    lumbri- 
coides,  etc.,  184,  185 
Instruments,  scientific,  manufacture  of,  496 
Insulating  wire,  manufacture  of,  604 
Insurance,  health,  818 

method  of  compensation,  814 
in  Great  Britain,  815 
Iodine  compounds,  manufacture  of,  539 
Iron  carbonyl,  585 

Iron  and  foundry  workers,  anaemia  among, 
238 
arteriosclerosis  among,  245 
chronic  endocarditis  among,  243 
primary  cardiac  overstrain  among,  240 
Iron  ore,  smelting  of,  in  the  blast  furnace, 
49 


9o6 


INDEX    OF    SUBJECTS 


Iron  sanitary  ware,  factories,  603 
and  steel  industry,  586 

injuries  to  the  eye  arising  out  of,  308 
structural  workers,  598 

Japans,  manufacture  of,  551 
Jarring  of  the  body,  446 
Jewelry,  manufacture  of,  581 
Junk,  workers  in,  498 
Jute,  manufacture  of,  654 

Karbunkelkrankheit  {see  Anthrax),  158 
Kehl  bridge  (cf.  compressed-air  illness),  188 
Kidneys,  changes  in,  effects  of  poisoning 
by  arseniuretted  hydrogen  gas  on, 
7,  8, 
in  acute  nephritis,  247 
in  chronic  interstitial  nephritis,  248 
Knock-knee,  444,  598 

Label  licking,  668 

Laboratory  workers,  injuries  to  the  eye  of, 

308 
Labor  and  Health  Boards,  855 
federal  activities,  855 
Illinois,  858 
^Maryland,  859 
Massachusetts,  861 
Michigan,  859 
Missouri,  859 
New  York,  860 
Ohio,  860 
Pennsylvania,  861 
States,  857 
Wisconsin,  862 
casual,  456 
Law,  child,  852 
Laborers'  day,  717 
Lace  workers,  654 
Lard,  manufacture  of,  691 
Laundry  workers,  662-665 
Law,  child  labor,  852 
enforcement  of,  865 
European  labor,  804 
notification  of  enforcement,  827 
Laws,  European,  texts  where  found,  804 
Lawyers,  703 

Lead,  channels  of  entrance  of,  into  the  body, 
82,83 
desilvering  of,  78 

smelting  of,  and  cases  of  arsenic  poison- 
ing, 6 


Lead  tests  to  determine  the  presence  in  air 
of  104,  105 
use  of,  {see  Zinc),  18 
Lead  absorption,  98 
colic,  773 

compounds,  workers  in,  512 
in    drinking    water,   what    amount   is 

dangerous?  76 
dust,  inhalation  of,  83 
in  the  nasopharynx,  83 
in  the  stomach,  blood,  and  kidneys, 

83 
foil,  606 
as  a  hardening  and   tempering  agent, 

poisoning  from  the  use  of,  103,  104 
industries,    special    rules    required    in 

certain,  105 
in   urine    and   stools,  impracticability 

of,  in  general  practice,  96,  97 
presence  of,  in  lead  poisoning,  96,  97 
legislation,  805,  808 
line,  role   of   the,  in   the  diagnosis  of 

lead  poisoning,  97 
melting  in  printing  shops,  612 
mining,  poisoning  among  workers    in, 

113 
ore,  smelting  of,  77,  78 
oxides,  dangers  in  the  roasting  of,  107 
painted  surfaces,  sand  papering,  517 
pigments,  dry,  5x7 

pipe,  cases  of  lead  poisoning  in  mak- 
ing, 103 
effect  of  presence  of    metals  other 

than  lead  on  drinking  water,  76 
influence  of  water  on  new  and  old,  76 
manufacture  of,  515 
Lead   poisoning — By   Sir   Thomas    Oliver, 

75-95 
among  brass  casters  and  polishers,  28 
painters,  115-117 
among  porcelain  workers,  in 
among  workers  in  tiles,  no 
basophilic  degeneration  of  the  red  cells 

in,  97 
cases  of,   among   white   and  red  lead 
workers,  108 
from  records  of  the  Massachusetts 

General  Hospital,  98-100 
in  New  York  City,  103-106 
in  New  York  State,  103 
in  potteries.  Great  Britain,  in 
causes  of,  306 
delay  in  the  diagnosis  of,  96-100 


INDEX    OF    SUBJECTS 


907 


Lead  poisoning,  diagnosis,  91-92 

early  diagnosis  of,  96-101 
early  symptoms  of,  loi 

e\'idence  of,  among  59  of  100  able 
bodied  patients  examined  by  Hay- 
hurst,  116 

from  fumes  from  melted  lead  and  dust 
in  the  manufacture  of  storage 
batteries  q.v.,  115 

importance  of  history  of  exposure  to, 
98-101 

in  china  and  earthenware  trades,  82 

in  the  manufacture  of  rubber  goods,  117 

in  potteries,  630-632 

presence  of  lead  in  urine  and  stools  in, 
96,  97 

prevention  of,  514 

references,  95 

reported  as  brass  poisoning,  102 

r6le  of  the  lead  line  in  the  diagnosis  of, 

97 
of  stippling  in  the  diagnosis  of  {see 
Basophilic  granules),  99 
see  babbitting,  21 
sources  of,  75 
symptomatology,  83-91 
treatment,  92-95 
variation  of  symptoms  of,  1 26 
Lead  poisoning  and  absorption  {^see  Legge 
and  Goadby),  133 
in  food,  tinned  food,  76 
in  Illinois,  102,  103 
in  the  United  States,  117,  118 

references,  117,  118 
red,    as    to    harmfulness  of  {see    Red 

lead),  78 
smelting,  513 

and  refining,  dangers  of,  114 

statistics  on  cases  of  lead  poison- 
ing, 113 
State  regulations,  805,  el  seq. 
workers  exposed  to  lead  poisoning, 
103 
white  {see  White  lead),  513 

manufacture,  79 
workers,  ateriosclerosis  among,  245 
chronic  endocarditis  among,  243 
chronic  interstitial  among,  248 
dangers  from  chewing  tabacco,  82 
Wassermann  reaction  among,  90 
Leaf  metal  workers,  583 
Leather-workers'  insanity,  from  the  use  of 
carbon  bisulphide  in  gutta-percha 
solvent,  36 


Legislation,  accident  and  disease,  873 
Bulgaria,  818 
effective,  867,  869 
equipment,  preventive,  873,  875 
France,  817 
Germany,  817 
Great  Britain,  815 
Health  insurance,  818 
insurance,  818 

compensation,  814 
Ontario,  817 
safety,  868 
Switzerland,  818 
methods  and  scope,  802 
of  prohibition,  804 
of  regulation  in  Australia,  817 
ankylostomiasis,  815 
anthrax,  812 
bisulphide  carbon,  811 
brass,  808 
chroma tes,  811 
compressed  air,  809 
dusts,  808,  810,  811 
in  Europe,  805,  810 
glass  blowers,  813 
lead,  805,  808     '^' 
mercury,  812 
tobacco,  812 
in  United  States,  805 
Legislative  Commissions,  855 
Life  saving  service,  707 
Light,  artificial,  437 

natural,  437 
Lighting,  437 
Lime  burning,  632 
Limestone,  smelting  of,  in  the  blast  furnace, 

49 
Linen  industry,  653 
Linoleum,  manufacture  of,  551 

and  oil  cloth,   lead   poisoning   among 

workers  in  the  manufacture  of,  104 
Linotyping,  611 

Linseed  oil,  manufacture  of,  551 
Litharge,  manufacture  of,  106—108 
Lithographers,  diseases  of,  614 
Lithopone,  503 
uses  of,  18 
Litho-transfer    works,    lead    poisoning    in 

employees  of,  102 
Lockers,  443 
Lodging  houses,  460 
Lumber  camps,  673 
Lunch  rooms,  443 
Lyddite,  manufacture  of,  560 


9o8 


INDEX    OF    SUBJECTS 


Maine,  notification  of  occupational  diseases, 

825 
Malaria,  definition  of,  174 

epidemiologic  factors  of,  175 
importance  of,  in  laborers,  175 
pathogenesis  of,  174 
proph3'laxis  and  treatment,  175,  176 
results  of  mosquito  campaigns,  175 
varieties  of  causative  organism  of,  174 
Malignant    anthrax  oedema,  mortality  in, 
170 
pustule  {see  Anthrax),  also  malignant 
anthrax  oedema,  170 
Manganese,   an  industrial  poisoning,  119- 
125 
toxicology  of,  119 
workers  in,  625 
Manganese     poisoning — By    Louis     Casa- 
major,  11 9-1 2  5 
pathology  of,  122-124 
references,  125 

symptomatology  of,  120,  122 
treatment  of,  124 
Mania,  273 

Maniac,  depressive  psychosis,  279 
Manual  neuroses,  286-289 

artists'  cramp;  cigar  makers'  cramp; 
granite  cutters'  cramp;  hammer- 
mans'  cramp;  pianists'  cramp; 
sewing  and  scissors  cramp;  teleg- 
raphers' cramp;  typewriters' 
cramp;  violinists'  cramp. 
Marble  workers,  625 

Maryland  Labor  and  Health  Boards,  859 
notification   of   occupational   diseases, 
825 
Massachusetts  Lal)or  and  Health  Boards, 
861 
notification  law,  825 
Match  heads,  utilization  of  phosphorus  in 
the    composition    of,    in    Vienna, 
1833,  153 
Matches,  manufacture  of,  145,  152,  553 
non-phosphorus,  151 
patent  for  use  of  friction,  granted  to 

Alonzo  Philips,  153 
prohibition  of   manufacture   of   white 
phosphorus  through  international 
convention,  157 
of    white     phosphorus     in     United 
States  by  means  of  a  prohibitire 
tax,  157 
See  Phosphorus. 


Mattresses,  manufacture  of,  577 
Meat  packing  industry,  690 
Medical  profession,  relation    to   control  of 
occupational  disease,  821 
schools,  relation  to  control  of  occupa- 
tional disease,  821 
industrial  diseases,  821 
Meerschaum,  632 
Melancholia,  273 
Melinite,  manufacture  of,  560 
Meltzer's  resuscitation  apparatus,  423 
Menus,  for  summer,  479 

for  winter,  478 
Mercantile  pursuits,  708 
Merchant  Marine  Service,  706 
Mercurialism,    industrial,    cardinal    symp- 
toms of,  130 
peculiar    copper    colored    redness    in 
trachea  and  mucous  membrane  of 
mouth  a  symptom  of  habitual,  131 
Mercurial  stomatitis,  127 

tremor,  not  always  evidence  of  stoma- 
titis with,  131 
Mercury,  acute  poisoning  from  an  inunc- 
tion with  blue  ointment,  132 
amount  of,  necessary  to  cause  poison- 
ing, 132,  133 
compounds,  manufacture  of,  529 
entrance  of,  into  body,  see  Lang,  132, 

fulminate,  570 

in  gold  and  silver  extraction,  526 
in  manufacture   of    electrodes    and 
storage-batteries,  528 
legislation,  812 
mining,  527 

receptiveness  for,  132,  134 
Mercury   poisoning — By   Ludwig    Teleky, 
126-135 
prevention  of,  533 
references,  135 

relation  of  intake  of  the  poison  to 
clinical  picture,  126 
symptomatology  and  pathology,  126- 

131 
treatment  of,  134,  135 
Mercury  pumps,  524 

smelting,  521 
Metal-etching,  615 
Metallochrome,  614 
Metals,    cases   of    arsenic   poisoning    from 

smelting  of,  6 
Methane,  620 


INDEX    OF    SUBJECTS 


909 


Methemoglobinemia,  236 
Methyl  bromine  poisoning,  539 

chloride  poisoning,  540 

oidine  poisoning,  539 
Mexican  blue  gum  wood,  675 
Mica,  632 
Michigan  Labor  and  Health  Boards,  859 

notification  law,  825 
Microbes  in  air,  779 
Milan, abortions,  771 

assistance  to  patients,  769 

clinic,  765  « 

consultations,  772 

didactic  activity,  767 

dusts,  770 

lead  colic,  773 

occupational  factors,  768 

overexertion,  results  of,  770 

patient  statistics,  776 

pellagra,  771 

phosphorism,  771 

popular  propaganda  of  hygiene,  774 

researches,  774 

workmen,  consultation  with,  772 
MiUer's,  diseases  of,  685 
Millstone  cutting,  627 
Milzbrand  (see  Anthrax),  158 
Milzfieber  (see  Anthrax),  158 
Mineral  wool,  640 
Miners,  accidents  of,  618 

anaemia  among,  238 

chronic  endocarditis  among,  243 

diseases  of,  622 

lamps,  use  of  phosphorus  in  the  mak- 
ing of,  146 

phthisis,  223,  784 

primary  cardiac  overstrain  among,  240 

safety  rules,  784 

zinc,  16 
Mines,  air  of,  619 

carbon  monoxide  in,  620 

copper,  15 

explosive  conditions  in,  621 

submarine,  manufacture  of,  561 

subterraneous,  manufacture  of,  562 
Mining,  carbon  monoxide  poisoning  in,  55 
Ministers,  702 

Minnesota,  notification  law,  825 
Minors  in  dangerous  occupations,  847 

age  limit,  851 

labor  law,  852 
Mirror  workers,  529 
Missouri  Labor  and  Health  Boards,  859 


Missouri  laws  of  notification,  825 
Mittens,  leather,  manufacture  of,  575 
Mogipnonia,  271 
Monotyping,  611 

]Mortality,  records  of  occupational  disease, 
828 

comparative  in  tuberculous,   781 

occupation  statistics,  780 

statistical  charts,   799,  800 
Moth,  brown-tailed,  430 
Moulders  in  brass  foundries,  491 

iron  foundries,  597 
Mouldings,  manufacture  of,  677 
Mountain  climbing,  211 

sickness,  211 
Mouth,  care  of,  466 

effect  of  dust  and  fumes  upon,  298 

occupational  affections  of — By  T.  M. 
Legge,  296-306 
Mower  mite,  430 
Multiple  sclerosis,  280 
Municipal  Local  Health  Organization,  863 

administrative  law,  864 
control,  865 
Munition  workers  in  Great  Britain,  health 

of,  570 
Muscular  paresis,  274 
Museums  of  safety,  American,  n,  13 
Musicians,  703 
Myotonia,  273 

Nail,  causes  of  disease  of,  374 

Naphtha  and  benzole  poisoning — By  Dr. 
Ahce  Hamilton,  136-144 

Naphthalene,  543 

Nasal  septum,  effect  of  chrome  dust  on,  305 

Navy,  705 

Neckwear,  465 

Needle  polishers,  600 

Nematodes,  177 

Nephritis,  acute,  247 

chronic  interstitial,  248 

Nervous  system,  effects  of  lead  on,  88-91 

Neuritis,  peripheral  neuritis  from  arsenic 
poisoning,  5 

Neuroses  (see  Occupation  neuroses),  270 

New  Hampshire  law,  notification,  825,  826 

New  Jersey  law,  notification,  825 

New  York  City,  cases  of  phosphorus  poison- 
ing reported  in  1855  and  1864  in, 

New  York  State  Labor  Commission,  860 
Labor  and  Health  Boards,  860 


9IO 


INDEX    OF    SUBJECTS 


New  York  State  notification  law,  825 

rules  relating  to  caisson  work  proposed 
by     engineers,     contractors     and 
doctors  to,  202,  203 
regulations  for  tunnel  work,  203,  204 
Nickel,  584 

carbonyl,  584 
plating,  585 
Nightmen,  718 

Nitric  acid,  manufacture  of,  537 
Nitrobenzol,  544 
Nitrochlorobenzene,  545 
Nitroglycerine,  head,  559 
manufacture  of,  558 
Nitroso-compounds,  545 
Nitrous  fumes,  570 
Nose,  care  of,  466 

chrome  compounds  and  their  effects  on, 
299,  300 
I.  manufacture;  2.  uses. 

(a)  dyeing  and  calico  printing;  {b) 
French    polishing;     (c)   photog- 
raphy   and    litho-etching;     (d) 
tanning  leather, 
effect  of  dust  and  fumes  upon,   296, 

297 
nature  of  perforation  of,  302,  303 
Occupational  affection  of — By  T.  M. 

Legge,  296-306 
perforation  of,  302 

I.  cause, 
perforation  of  septum  from  action  of 
salts  of  arsenic,  5 
Nose  affections,   preventive   and  remedial 
measures  of,  303 
mouth  and  throat,  occupational  affec- 
tions of,  297 
I.  cotton  waste  sorting;  2.  flannelette 
raising;  3.  fur  puUing. 
Notifiable  occupational  diseases,  421 
Notification  of  occupational   diseases,   820, 
824 
by  whom  made,  821 

information  in  reports,  823 
enforcement  of,  827 
fees,  undesirable,  823 
form  of  certificate,  829 
reasons  for,  820 
relation  of  physician  to,  821 
state  laws,  825  ct  scq. 
state  rights,  822 
to  whom  made,  822 
Nurses,  702 


Occupational  disability  in  U.  S.  Navy,  719 
diseases,  classification  of,  417 
certificate  of  death,  828,  829 
definition  of,  417 
etiology,  417 

methods  of  legislation,  802 
mortality  records,  828 
notificable,  421,  820 
physician's  knowledge  of,  824 
prevention  of,  802 
relation  to  other  diseases,  824 
reporting  cases  of,  820 
specific,  417 
systemic,  417 
dyskinesia,  270 
intoxication,  3,  157 
risks  in  U.  S.  Navy,  719 
Occupation  Neuroses — By  E.  E.  Southard 
and  H.  C.  Soloman,  270-295 
arterial  spasm  theories,  273 
central  nervous  theory,  273,  274 
constitutional  factors  or  diatheses,  271 
fundamental  studies  on,  270 
general  neurasthenic  condition,  272 

prognosis  and  treatment  of,  289-291 
hysterical  phenomena,  272 
manual,  286-289 
myotonia,  273 
other  forms  of,  289 
I.  pedal  neuroses. 
(a),  dancers'  cramp, 
over-exertion,  272,  273 
peripheral  theories,  274,  275 
prognosis  and  treatment,  289 
references,  291-295 
spasm   with   functional   impotence   of 

muscles,  274 
theories  of  origin  on,  271-275 
tics,  272 

varieties  of,  276-282 
vocations  giving  rise  to,  276 
Occupations  in  Illinois  involving  risk  of  lead 
poisoning,  number  of,  10 1 
in  New  York  State  involving  exposure 
to  lead,  103-117 
Ohio  Labor  and  Health  Board,  860 

notification  of  industrial  disease,  825 
Oil  cloth  (see  Zinc),  18 
manufacture  of,  551 
and  grease,  use  of  carbon  bisulphide  for 

extraction  of,  36 
fields  and  refineries,  fatal  cases  of  poi- 
soning in,  139 


INDEX    OF    SUBJECTS 


911 


Olefiant  gas,  620 

Oleomargarine,  manufacture  of,  6yi 

Ontario,  Compensation  Acts,  817 

Open-hearth  steel  works,  588 

Ophthalmia  electrica,  588 

Orange  mineral,  manufacture  of,  106-108 

Organ  pipe,  manufacture  of,  676 

Osteomyelitis  in  pearl  workers,  644 

Over-exercise,  effects  of,  446,  469 

Overstrain,  446 

Overwork,  447 

Oystermen,  707 

Oxy-acetyline  blow  pipes,  use  of  by  bra- 
ziers and  hard-solder  workers,  23 

Oxygen  apparatus,  423 

in  treatment  of  acute  secondary  anaj- 
mia,  238 

Ox5^-hydrogen  blow  pipes,  use  of    by  bra- 
ziers and  hard-solder  workers,  23 

Paint  and  color  works,  cases  of  arsenic  poi- 
soning in,  6 
Painters,  arteriosclerosis  among  {see  House 
painters),  80,  245 
lead  poisoning  among,  516,  517 
prevention  of  lead  poisoning,  519 
Painting,  42  cases  of  lead  poisoning  among 

workers  in,  104 
Paint  industry,  550 

Paint,  scraping  of,  cases  of  arsenic  poison- 
ing resulting  from,  6 
Paints,  dangerous  ingredients,  516 

symptoms  due  to  "driers"  added  to,  81 
Paper  box  and  card  workers,  668 
hangers,  635 
manufacture,  667 

poisoning  from  arseniuretted  hydro- 
gen  gas  among   workers  engaged 
in,  7 
works,    poisoning   from    arseniuretted 
hydrogen  gas  in  dissolving  block 
tin,  q.v.,ii,  12 
Papillomata,  paraffin  workers  develop,  139 
Paraffin  workers,  skin  affections  of,  139 
Paralysis  agitans,  280 

anapeiratic,  270 
Paralytic  writers'  cramp,  281 
Parasites,  animal,  429 

and  occupation — By  Bailey   K.    Ash- 
ford,  173-186 
Parchment  paper  {see  Zinc),  uses  of,  18 
Paris  green,  3 
Parkinson's  disease,  272 


Pastry  cooks,  687 

Patent-leather,  manufacture  of,  574 

Pearl  buttons,  manufacture  of,  643 

Pediculosis  ,430 

Pellagra,  771 

Pennsylvania    Labor    and   Health   Boards, 

861 
Percussion  caps,  manufacture  of,  555 

notification  law,  825 
Personnel  of  United  States,  physical  disa- 
bility of,  718 
Petroleum  and  its  distillates,  136-140 
fumes,  poisoning,  622 
products,  toxic  action  on  skin  by,  139 
workers,  547 
Pewter  goods,  605 
Phenol,  544 

Philosophers'  wool  {see  Molten  zinc),  18 
Phosgene,  540 
Phosphor  bronze,  phosphorus  poisoning  in 

the  use  of,  145 
Phosphorisne  (Milan),  771 
Phosphorus,  danger  incident  to  the  use  of 
white,  155 
danger  of  necrosis  in  the  preparation 

of,  145 
discovery   by   Walker  of   the  ignition 

of  by  friction,  153 
utilization    of,    in   the  composition  of 

match  heads,  in  Vienna,  1833 
white  or  yellow,  discovered  by  Brand 
in  1669,  153 
Phosphorus  chloride,  540 

matches,     fundamental     processes    in 

manufacture  of,  154,  155 
varieties  of,  153,  154 
Phosphorus  poisoning — By  Dr.  Alice  Ham- 
ilton, 145-152 
chronic, 
first    recorded    case    of,    in    America, 

146 
pathology    and    symptomatology    of, 

147-151 
prevention  of — By  John  B.  Andrews, 

153-157 
(industrial),  preventive  measures,  156, 

157 
references,  151,  152 
treatment  of,  151 
Phosphoretted  hydrogen  poisoning,  487 
Photoengraver,  615 
Photographers,  616 
Phthisis,  industrial,  785 


912 


INDEX    OF    SUBJECTS 


Phthisis,   brass  workers,    undue   incidence 
among,  28 
miners,  784 
Physical  apparatus  makers,  524 

disability  among  U.  S.  workers,  718 
Physicians,  702 

knowledge  of  occupational  hazards,  824 
liability  for  failure  to  report,  826,  827 
relation    to    control    of    occupational 
disease,  821 
industrial  hygiene,  768,  821 
Pianists'  cramp,  287 
Pianos,  manufacture  of,  676 
Piano   wires   and   springs,   lead   poisoning 
acquired  in  the  manufacture  of,  104 
Picric  acid,  545,  560 
Picture  frame  makers,  677 
Piecework,  264 
Pilots,  707 
Pine  oil,  613 
Planing  mills,  673 
Plankers  acid,  531 
Planters,  670 
Plasterers,  634 
Plate  printers,  615 
Plumbers  and  plumber  supplies,  515 
Plumbism  {see  Lead  poisoning),  75 

(see  Zinc),  17 
Pneumokoniosis,  219 

causation  of,  in  general,  224,  225 
pathology,  227-229 
prognosis,  226,  227 
symptomatology,  225,  226 
treatment,  232-234 
Pneumonia  in  blast-furnace  workers,  778 
broncho,  terminating  a  gas  poisoning, 

63 
influence  of  floor  space,  431 
Polishers  of  steel,  599 
of  stone,  635 
of  wood,  675 
itch,  676 
Porcelain  enamelled  sanitary  ware,  manu- 
facture of,  III,  112 
Porters,  primary  cardiac  overstrain  among, 

240 
Portrait  painting,  fatal  cases  of  lead  poison- 
ing due  to,  103 
Potteries,  cases  of  lead  poisoning  in  Great 

Britain,  in 
Pottery,  percentage  of  fatal  cases  of  lead 
poisoning  in  i)crsons  employed  in 
its  manufacture,  82 


Pottery  industry,  629 

exposure  to  lead  in,  108-110 

Precious  stones,  polishing  of,  636 

Preserving  industry,  693 

Prevention  of  occupational  disease  by  noti- 
fication, 821 

Printers,  dangers  to,  82 

diseases  of,  609,  612,  613 

Printing  and  publishing  industry,  609 

trades,    lead    poisoning    among    em- 
ployees in,  103 

Producer  gas  used  as  fuel  in  producing 
steam  and  electricity  or  for  heating 
purposes,  54 

Protection,  child-birth,  843 
of  health  of  women,  831 

Protozoa,  174  \ 

Pseudo-brass  poisoning,  22 

Pseudo-myasthenia,  cases  of,  reported  by 
Gowers,  138 

Psychoses      following     carbon     monoxide 
poisoning,  64,  65 
(see  Occupation  neuroses),  270 

Ptilosis,  438 

Puddlers,  cataract  in,  588 

Puddling,  588 

Pulmonary  anthrax,  frequency   and    mor- 
tality, 168 
tuberculosis  in  dusty  work,  777 

Pulmotor,  423 

Pyridine,  544 

Pyroxyline,  manufacture  of,  556 

Quarries  and  mines,  injuries  to  the  eye  in, 

308 
Quarrymen,  diseases  of,  622 

Radium,  acute  reactions  due  to,  398 

avoiding  injurious  effects  by  contact 
of  fingers  with  the,  399 

references,  400,  401 

summary  and  conclusions,  400 

symptoms  and  signs  produced  by,  397 

workers,  641 
changes  in  blood  of,  399 
Rag  dust,  811 

industry,  666 

pickers'  disease  {see  Anthrax),  158 
Railway  employees,  diseases  and  accidents 

of,  711 
Rattan  factories,  676 
Ray  cataract,  638 
Raynaud's  disease,  285 


INDEX    OF    SUBJECTS 


913 


Red  lead,  danger  of  dust  and  fumes  from, 

78,79 

manufacture  of,  io6-io8 
Refuse  pickers,  718 

Regulated  employment  of  women,  835 
Rendering  plants,  680 
Relation  of  compensation  to  safety,  871 
Reporting  occupational  disease,  820 

reasons  for,  820 

by  whom,  821 
Respirators,  442 
Rest  in  chronic  endocarditis,  244 

in  treatment  of  anaemia,  239 

in  treatment  of  primary  cardiac  over- 
strain, 240 
Restaurant  employees,  699 
Retouchers,  lead  poisoning  among,  102 
Rheumatic  fever,  acute,  endocarditis  in,  242 
Rheumatism,  277 

Rhode  Island,  notification  law,  825 
River-tunnel  construction  {see  Compressed 

air  illness),  188 
Riveters,  598 
Roburite,  560 

Rontgen  tubes,  manufacture  of,  640 
Rontographers,  640 
Rolling  mills,  589 
Roofers,  606 

Rubber  balls  and  toys,  cases  of  lead  poison- 
ing  in  making,  103 

bufl&ng,  508 

calendering,  506 

cement  makers,  exposure  of  to  carbon 
bisulphide,  36 
manufacture  of,  510 

compounding,  506 

dipping,  508 

goods  manufacture,  cases  of  lead  poison- 
ing in  the  course  of,  117 

industry,  poisons  employed  in,  505 
uses  of  carbon  bisulphide  in,  35-37 

mixing  mills,  506 

reclaiming,  511 

sundries,  manufacture  of,  508 

tire,  manufacture  of,  508 

vulcanizing,  509 

washing,  506 
Rugs,  manufacture  of,  653 

Sabicu  wood,  674 

Safety  Council,  National,  13 

equipment,  873 

relation  of  compensation  to,  871 


Safety  Council,  National,  rules,  875 
Sagger  making,  629 
Sailors,  diseases  of,  705 
Salamanders  {see  Gassing),  634 

fumes  of,  55 
Sandblasting,  596 
Sandpaper,  manufacture  of,  636 

dust,  677 
Sandpapering,  517 
Satin  wood,  675 

Saturnine  encephalopathy  {see  Lead  poison- 
ing!, 87 
Saturnism  {see  Lead  poisoning),  75 
Scabies,  430 
Scavengers,  718 

Scheele's  green  {see  Arsenite  of  copper),  3 
Schweinfurt  green,  3 

Scientific  management  and  fatigue,  267,  268 
Scissors  cramp,  287 
Sclavo's  serum,  578 
Screws  {see  Compressed  air  illness). 
Securite,  560 
Septic  infections,  425 
Sequoia  wood,  674 
Servants,  700 
Sewing  cramp,  287 

"Sheep-dip,"   arsenic  poisoning   from    the 
manufacture  of,  6 

eflfects  on  workers  of  its  manufacture, 

4,  5 
Sheffield,  seat  of  cutlery  industry,  428 
Shellac,  arsenic  in,  551 
Shells,  manufacture  of,  562 
Shingle  stains,  manufacture  of,  550 
Ship  painting  {see  Painters'  trade),  116 
Shoddy,  manufacture  of,  666 

fever,  667 
Shoemakers,  diseases  of,  657 

exposure  of  to  cement  containing  car- 
bon bisulphide,  36 
Shotgun  powder,  manufacture  of,  558 
Shot  making,  cases  of  arsenic  poisoning  in,  6 
Shrapnel,  562 

Sickness    rates    in    different    occupations, 
749-761 

in  the  iron  and  steel  industry,  592 
Siderosis,  220,  438 
Silicosis,  220,  438 

and  tuberculosis,  229,  230 
Silk,  artificial  {see  Cellulose}. 
Silos,  danger  in,  from  carbon  dioxide,  672 
Silver  and  gold,  extraction  of,  526,  580 
Silversmiths,  582 


914 


INDEX    OF    SUBJECTS 


Singers,  703 

Skin,  action  of  salts  of  arsenic  on,  5 

affections  which  occur  in  animals  and 
may  be  transmitted  to  man,  372, 

373 
I.    actinomycosis;     2.    anthrax;    3. 
glanders. 

care  of,  462 

causes  of  dermatitis  of,  354 

I.   handling   various   foreign   wood; 
2.  workers  in  quinine  factories. 

causes  of  dermatitis  venenata,  351 
I.  poison  ivy;  2.  poison  sumach. 

causes  of  eczema  of,  354 

causes  of  trade  stigmata,  352 

chrome  compounds  and  their  effect  on, 
300-302 

dermatitis,  usually  of  an  eczematous 
type,  354 

discolorations  of,  352,  353 
I.  millers'  hands. 

effect  of  bichromate  solutions  on,  301 

effect  of  mercury  upon,  353 

erysipeloid  of,  374 

I.  causes;  2.  situation. 

introduction  of  serious  systemic  infec- 
tions into  the,  353 

jaundice  of,  from  inhalation  of  arseniu- 
retted  hydrogen  gas,  8 

occupational   affections   of — By   John 
T.  Bowen,  351-379 
bichromate  works,  302 

occupational  affections  of,  356-370 
I.  arsenic,  chlorine  workers;  2.  bak- 
ers; 3.  barbers;  4.  bartenders  and 
liquor  dealers;  5.  builders,  masons, 
brick  makers;  6.  chemical  and 
drug  workers;  7.  confectioners;  8. 
dressmakers  and  photographers; 
9.  dyers  and  aniline  workers;  10. 
flax  and  linen  workers;  11.  florists 
and  gardeners;  12.  furniture  pol- 
ishers; 13.  housemaids  and  house 
workers;  14.  metal  and  mineral 
workers;  15.  musicians;  16.  physi- 
cians, surgeons,  nurses,  etc.;  17. 
printers;  18.  sugar  refinery  work- 
ers; 19.  tar,  paraftlne  and  petro- 
leum workers;  20.  tobacco  work- 
ers; 21.  wood  workers. 

occupational  dermatitis,  or  trade  ecze- 
mas of,  3S4 
dermatoses  proper,  353 


Skin,  pyogenic  and  tricophytinic  infections 
of,  371 

sensitiveness  toward  irritants  of,  355 

thickening  of,  352 

treatment  of,  352 

tuberculosis  of,  373 
causes,  373 
Skin    affections,    "grain    itch"    prevalent 
among  farmers  and  laborers,  375 

miscellaneous  occupations,  374,  375 
I.  furriers;  2.  milkmen;  3.  theatrical 
profession. 

references,  377-379 
Sleep,  472 
Sliphouses,  629 
Smallpox,  425 

Smelting   (see  Blast-furnace   gas),   of  iron 
ore,  coke  and  limestone,  49 

of  lead  ore,  77,  78 
Smokeless  powder,  557 
Soap,  manufacture  of,  680,  681 
Soap-boilers,  arteriosclerosis  among,  245 
Social  betterment,  458 
Solder,  manufacture  of,  528 

rapid,  528 
Soldering  zinc,  fumes  from,  18 
Solder  workers  (hard),  23 
Soldiers,  chronic  endocarditis  among,  243 

diseases  of,  704 

primary  cardiac  overstrain  among,  240 
Solenite,  manufacture  of,  557 
Solingen  seat  of  cutlery  industry,  428 
South  African  Miners'  Phthisis  Commission 

of  191 2,  report  of,  299 
Spasm,  functional,  270 

right-sided,  270 
Specialization  and  speed  of  work,  259,  260 
Speeding  up,  447 
Spelter  {see  Zinc),  17 

a  frequent  source  of  plumbism  among 
furnace  men,  78 
Spelter  workers,  tj^es  of  symptoms  of  lead 

poisoning  in,  78 
Spices,  manufacture  of,  695 
Spinning  machines,  9 
Splenic  fever  (see  anthrax),  158 
Stamp  lickers'  tongue,  668 
Starch,  manufacture  of,  688 
State  Laws,  notification  acts,  825 

analytical  summary  of,  827 

enforcement  of,  827 
Statistics,  averages,  misuse  of,  793 

classifications  of,  792 


INDEX    OF    SUBJECTS 


915 


Statistics,  death  rates,  795 
dusts,  777 
fallacies  of,  789 
future  demography,  801 
gases,  777 
methods  of,  790 
mortality,  780,  et  seq. 

charts,  799,  800 
ratios,  793 

relating  to  occupational  diseases,  777 
tabulation,  792 
variations,  794 
Steam-fitters,  515 
Steel  grinders,  599 

industry  {see  Carbon-monoxide  poison- 
ing), 
blast-furnace  gas  in,  49 
carbon-monoxide   poisoning  in,  49- 

52 
magnets,  lead  poisoning  resulting  from 
the  hardening  of,  104 
Stereotyping,  612 
Stockings,  465 
Stokers,  706,  708 

acute  endocarditis  among,  242 
arteriosclerosis  among,  245 
Stomatitis,  industrial  mercurial  poisoning 

and, 127 
Stonecutters,  625-627 

palsy  of,  275 
Stone   dust,  811, 
masons,  634 
Stoneware,  629 
Storage  batteries,  497,  528 

or  electric  accumulators,  dangers  from 

fumes  from  melted  lead  and  dust 

in  the  manufacture  of,  115 

battery  plants,  cases  of  lead  poisoning 

among  workers  in,  103 

"Store  plates,"  poisoning  from  arseniureted 

hydrogen  gas,  while  dipping,  12 
Straw  hats,  manufacture  of,  553 
Street  cleaners,  717 

railway  employees,  714 
Strikers   arthritis,  598 
Strongyloides  stercoralis,  importance,  184 

laboring  classes  chiefly  affected,  184 
Subway  employees,  715 
Sugar  refineries,  688 

Sulphate  of  copper  {see  Arsenite  of  soda),  3 
Sulphemoglobinemia,  236 
Sulphur,  use  of  carbon  bisulphide  in  extrac- 
tion of  from  ores,  36 


Sulphur  chloride,  540 

Sulphuric  acid,  manufacture  of,  536 

precautions  in  the  process  of  de-arseni- 
cating  sulphuric  acid,  6,  7  _ 
Sunstroke,  435 
Surfmen,  707 
Switzerland,  legislation,  818 

phosphorus     necrosis     among    match 
makers  in,  155 
Sjqjhilis,  277 

Tabacosis,  438 

Tabes  dorsalis,  272 

Tachycardia,  241 

Tagayasa  wood,  674 

Tailors,  660 

Tallow,  manufacture  of,  680 

Tanners,  diseases  of,  572 

Tanning,  cases  of  arsenic  poisoning  among 

tanners,  6 
and  dressing  processes,  573 
Taxidermists,  576 
Taylor  electric  process,  carbon  bisulphide  in 

America  made  bj',  35 
Teachers,  702 
Teamsters,  717 
Tea  tasters,  699 
Teeth,  care  of,  466 
Telegraph  operators,  709 

cramp  of,  286 
Telephone  operators,  709 
Temperature,  433 
Tempering,  601 
Terra  cotta  industry,  629 
Tests  for  the  presence  of  lead  in  the  air — 

By   C.   T.    Graham    Rogers   and 

John  H.  Vogt,  104,  105  ■ 
Tetanus,  426 

Tetany  in  shoemakers,  657 
Tetrachloride  of  ethane,  570 
Tetra-nitro-mcthyl-aniline,  570 
Tetrye,  570 
Textile  dust,  810 
Thomas  slag,  682 
Threshing  of  grain,  tire  and  dust  explosions, 

684 
Throat,  occupational  affections  of — By  T. 

M.  Legge,  296-306 
Tiles,  manufacture  of,  no 
Tin,  poisoning  from  arseniureted  hydrogen 

gas  in  dissolving  block  tin,  1 1 
Tin  foil,  606 

industry,  604 


9i6 


INDEX   OF    SUBJECTS 


Tin  pails,  lead  poisoning   acquired  in  the 
making,  103 
plate  works,  poisoning  from  arseniu- 
reted      hydrogen      gas       among 
employees  in,  7 
plating,  605 
Tinkers,  606 

Tinning,  case  of  lead  poisoning  in,  103 
Tobacco,  277 

effects  of,  482 
habit,  481 
heart,  482 
legislation  for,  812 
testers,  698 

workers,  diseases  of,  696 
Toe  dancers'  cramp,  289 
Tonite,  manufacture  of,  557 
Tonsillectomy,    as    prophylactic    of    rheu- 
matic endocarditis,  242 
Torpedo  war  heads,  561 
Toys  {see  Arsenite  of  copper),  manufacture 

of,  3 
Transmission    belt    makers     {see    Carbon 

bisulphide),  uses  of,  37 
Trauma,  277 

Trematodes,    importance    of    infection    to 
laborers,  185 
prophylaxis,  186 
schistomiasis  japonicum,  185 

mansoni,  185 
schistosoma  dysentery,  185 
hematobium,  185 
Trichina  spiralis,  430 

Trichinosis,   causative   worm   and   its   life 
history,  183 
clinical  forms,  183 
prophylaxis,  183 
treatment,  183 
Trichuris  trichuria,  importance,  184 
Trinitrotoluol,  570 
Trinitrophenol,  545 
Tuberculosis,  air  analysis  in,  779 
classes  affected  by,  483 
comparative  mortality,  780,  781 
definition  of  dusts,  778 
general  conclusions,  787 
in  gold  miners,  230 
industrial,  426,  429,  484,  785 
in  dusty  trades,  777 
relative   frequency   in    mine    workers, 
623,  784 
incidence,  782 
Tunnel  digging,  gasoline  poisoning  occur- 
ring in,  138,  139 


Tunnel  workers,  622 

occupational  disease  among,  187 
Turpentine,  as  a  "drier"  added  to  paints, 

effect  of,  on  health,  81 
Type  founding,  610 
metal,  610 
setting,  611 
Tjrpe writers'  cramp,  271,  286 

Uncinariasis,  424 

causative  parasites,  177 

definition,  177 

importance  of  disease  to  laborers,  181 

life  history  of  the  parasite,  177 

mode  of  infection,  177 

pathogenesis,  177 

Porto  Rico  system  of  country  dispen- 
saries, 181 

prophylaxis,  181 

results    of    uncinariasis    campaign    in 
Porto  Rico,  181 

sketch  of  clinical  forms  of  disease,  180 

soil  pollution,  177-180 

treatment,  181 

worm  carriers,  177 
Undergarments,  465 
United  States  workers,  physical  disability 

of,  718 
Upholstery,  577 
Uraemia,  in  acute  nephritis,  247 

in  chronic  interstitial  nephritis,  248 
Urine  {see  Lead) 

presence  of  lead  in,  in  lead  poisoning, 
96 

suppression    of,    from    poisoning    by 
arseniureted  hydrogen  gas,  8 

Vanadium,  606 

Varicose  veins,  444 

Varnish,  manufacture  of,  550 

Vegetable  Ivory,  643 

Venesection  in  acute  hemoglobin  trans- 
formation, 238 

Ventilation,  265,  432 

Vertigo,  partial,  270 

Veterinarians,  702 

Vienna,  cases  of  phosphorus  necrosis  in  the 
hospitals  of,  1866-1875,  155 

Vinegar,  manufacture  of,  695 

Violinists'  cramp,  287 

Virschow's  theory,  218 

Vision,  loss  of,  in  lead  poisoning,  88 

Vocational  neuroses  {see  Occupation  neur- 
oses), 270 


INDEX    OF    SUBJECTS 


917 


Voltage  {sec  Electrical  shock). 

definition  of,  403 

fatality  of,  to  man,  403 
Vulcanization,  509 

Vulcanizing  and  dissolving  rubber,  use  of 
carbon  bisulphide  for,  35 

Wall  paper,  cases  of  arsenic  poisoning  in 
manufacture  of,  6 
manufacture  of,  668 
preparation  of  {see  Arsenite  of  copper), 

3 

Wash  rooms,  443 

Watches,  manufacture  of,  583 

Water  gas,  carburetted  water  gas  for  illumi- 
nating purposes,  43 
composition  of  {see  Illuminating  gas), 

S3 
Waterproofing  and  spreading  of  rubber  {see 

Carbon  bisulphide;,  37 
Wax   solutions   and   waxed   paper,   use   of 
carbon  bisulphide  in  preparation  of,  36 
Weapons,  manufacture  of,  602 
Weave  rooms,  649 
Welding,  electric,  587 
Welfare  measures,  453 
by  employers,  456 
by  public,  457 
by  state,  454 
Wet  paint,  lead  poisoning  among  workers 

with,  103 
Whip  makers,  676 

White  arsenic,  cases  of  poisoning  from  the 
unloading  of,  6 
how  obtained,  3 

injurious   effects   on   workers   of   mix- 
tures with,  4 
damp,  620 

lead,    32    cases    of    poisoning    among 
workers  in,  104 
its  manufacture  (carbonate  of  lead), 

79-82 
manufacture  of,  106-108 
lead   workers,    42   cases   of    poisoning 
reported  by  Hobbs  among,    106 
lead  works,  lead  poisoning  among  work- 
ers in,  103 
metal  {see  Zinc,  uses  ol),  17 
phosphorus    matches,    prohibition    of 
manufacture  through  International 
convention,  157 
ware,   dangers   in    glazing    and    deco- 
rating, 108,  169 


Wire  cloth,  manufacture  of,  604 
industry,  603 

netting,  manufacture  of,  604 
Wisconsin  Industrial  Commission,  862 
Labor  and  Health  Boards,  868  et  seq. 
notification  law,  825 
Women,  childbirth  protection,  843 
eating  places,  844 
insurance,  845 

limitations  of  working  periods,  840 
medical  examination,  844 
night  work,  841 
prohibited  employment,  833 
protection  of  health,  831  et  seq. 
regulated  employment,  835 
Wood  alcohol,  551 
polishers,  675 
preservatives,  675 
stains,  675  • 
toxic,  674 
workers,  674 
Woolen  goods,  manufacture  of,  652,  653 
Wool    sorters,    acute   endocarditis   among, 

242 
Wool  sorters'   disease   {see  Anthrax),   also 

Pulmonary  anthrax,  158 
Work,  by  the  piece,  264 

certain  other  factors  of,  260 
clothes,  442 

specialization  and  speed  of,  259,  260 
Working  hours,  449 

length  of,  261-264 
Workmens'  compensation  act,  10 

hygiene  of,  461 
Workshops,  cleaning  of,  492 
Writers'  cramp,  270-290 
anomalous  cases,  281 
causes  of,  281 
degenerative  group,  281 
differential  diagnosis,  284,  285 
Ersatz  theories,  290 
examination  of  a  subject  with,  282-286 
neuritic  or  neuralgic  group,  281 
paralytic,  281 
range  of  treatment  of,  285 
spasmodic  group,  281 
"spastic"  cases,  279 
tremulous  form  of,  280 
true,  277-282 

neuralgic  form,  280 
paralytic  form,  279 
spastic,  278 
tremulous  form,  280 


9i8 


INDEX    OF    SUBJECTS 


X-ray,  carcinoma  result  of  exposure  to,  394 
causal  relation  of  cancer  and,  391 
degree    of    acute    reaction    following 

exposure  to,  391 
development  of  cancer  in  patients  who 
have  undergone  treatment  of,  393 
effect  of  exposure  to,  391 
general  effects  of,  396 
injuries,  prophylaxis  of,  397 
symptoms  caused  by,  394 
treatment  of,  3p6,  397 
I.  formula, 
radium — By  E.  E.  Tyzzer  and  Thomas 

Ordway,  391-401 
sarcoma  result  of  exposure  to,  394 
Xylene,  543 

Yards,  steel  plants,  589 
Yellow  brass  {see  Zinc),  16 
Youthful  workers,  444 

Zinc,  occupations  involving  the  use  of,  19-21 
I.  brass  and  bronze  alloys;  2.  enamel 
works;  3.  etching;  4.  galvanizing 
and   galvanic   battery   plates;    5. 
German    silver,    manufacture    of; 
6.  handling  of  zinc  salts;  7.  lead, 
de-silvering    of;    8.    lithographing 
plates;  9.   oil  cloth,  manufacture 
of;    10.   paint   works;    11.   parch- 
ment paper,  manufacture  of;  12. 
rubber   works;    13.    white   metal, 
manufacture  of;   14.   zinc  oxides, 
use  of. 
ores,  impurities,  16,  17 
tests  for,  17 
toxicity  of,  18 
uses  of,  17 
Zinc  ague,  491 

diagnosis  of,  21 
differential  diagnosis  of,  22 


I.  acute  bronchitis;  2.  Hodgkin's 
disease;  3.  influenza;  4.  la 
grippe;  5.  leukemia;  6.  septic 
processes;  7.  tonsillitis;  8.  tuber- 
culosis, 
occurrence  of,  19 
remedial   measures   (see   Part   2    for 

prophylaxis  of),  24 
symptoms  of,  20 
asthma,    differential     diagnosis     from 

antimony  poisoning,  23 
chills  (see  Zinc  ague),  19 

conditions  affecting  onset  and  sever- 
ity of,  20 
chloride,  540 

poisoning  from  arseniuretted  hydro- 
gen among  employees  engaged  in 
manufacture  of,  10-18 
galvanizing,  502 
miners,  501 

oxide,  manufacture  of,  502 
paints,  danger  from,  owing  to  pres- 
ence of  arsenic,  81 
freer     from     danger     than     lead 
paints,  81 
poisoning  —  By     E.     R.     Hayhurst 
(see  Zinc  ague),  16-22 
chronic  poisoning  not  produced,  21 
Edsall's  belief  concerning,  121 
references,  25 
poisoning  in  Illinois,   cases  of  sup- 
posed, 102,  103 
salts,  industrial  poisoning  from  18 
manufacture  of  (see  Arsenic  poison- 
ing), 18 
smelting,  17,  501 
in  Illinois,  103 
sulphate      manufacture,     poisoning 
from       arseniuretted       hydrogen 
among     employees    engaged     in, 
10-18 
workers,  diseases  of,  501 


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